hospital_name,last_updated_on,Version,hospital_location,hospital_address,license_number|MA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,
"Southcoast Hospitals Group, Inc.",11/1/2024,2.0.0,Charlton Memorial Hospital,"363 Highland Avenue,  Fall River MA 02720  ",V113,TRUE,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,modifiers,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,estimated_amount,standard_charge|min,standard_charge|max,standard_charge|methodology,additional_generic_notes
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,AETNA [1000108],AETNA [100010801],,,77.2,,1217.444,525.9295,1261.6,percent of total billed charges,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,AETNA [1000108],AETNA [100010801],,,77.2,,1870.556,808.0705,1938.4,percent of total billed charges,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,AETNA [1000108],AETNA [100010801],,,77.2,,1692.996,731.3655,1754.4,percent of total billed charges,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,AETNA [1000108],AETNA [100010801],,,77.2,,2565.356,1108.2205,2658.4,percent of total billed charges,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,AETNA [1000108],AETNA [100010801],,,77.2,,1376.476,594.6305,2483,percent of total billed charges,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,AETNA [1000108],AETNA [100010801],,,77.2,,1029.076,444.5555,1066.4,percent of total billed charges,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,AETNA [1000108],AETNA [100010801],,,77.2,,922.54,398.5325,956,percent of total billed charges,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,AETNA [1000108],AETNA [100010801],,,77.2,,3094.948,1337.0015,3207.2,percent of total billed charges,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,AETNA [1000108],AETNA [100010801],,,77.2,,2814.712,1215.941,2916.8,percent of total billed charges,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,AETNA [1000108],AETNA [100010801],,,77.2,,1555.58,672.0025,1612,percent of total billed charges,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,AETNA [1000108],AETNA [100010801],,,77.2,,3713.32,1604.135,3848,percent of total billed charges,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,77.2,,69.48,20.205,72,percent of total billed charges,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,77.2,,91.096,26.491,94.4,percent of total billed charges,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,AETNA [1000108],AETNA [100010801],,,77.2,,87.236,25.3685,90.4,percent of total billed charges,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,AETNA [1000108],AETNA [100010801],,,77.2,,61.76,17.96,64,percent of total billed charges,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,AETNA [1000108],AETNA [100010801],,,77.2,,60.988,17.7355,63.2,percent of total billed charges,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,AETNA [1000108],AETNA [100010801],,,77.2,,206.124,59.9415,213.6,percent of total billed charges,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,77.2,,69.48,20.205,72,percent of total billed charges,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,AETNA [1000108],AETNA [100010801],,,77.2,,217.704,63.309,225.6,percent of total billed charges,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,AETNA [1000108],AETNA [100010801],,,77.2,,206.896,60.166,214.4,percent of total billed charges,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,77.2,,218.476,63.5335,226.4,percent of total billed charges,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,AETNA [1000108],AETNA [100010801],,,77.2,,220.02,63.9825,228,percent of total billed charges,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,77.2,,221.564,64.4315,229.6,percent of total billed charges,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,AETNA [1000108],AETNA [100010801],,,77.2,,237.004,68.9215,245.6,percent of total billed charges,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,AETNA [1000108],AETNA [100010801],,,77.2,,326.556,94.9635,338.4,percent of total billed charges,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,AETNA [1000108],AETNA [100010801],,,77.2,,338.136,98.331,350.4,percent of total billed charges,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,77.2,,408.388,118.7605,423.2,percent of total billed charges,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,77.2,,408.388,118.7605,423.2,percent of total billed charges,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,AETNA [1000108],AETNA [100010801],,,77.2,,629.952,183.192,652.8,percent of total billed charges,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,AETNA [1000108],AETNA [100010801],,,77.2,,2998.448,871.958,3107.2,percent of total billed charges,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,AETNA [1000108],AETNA [100010801],,,77.2,,3775.852,1098.0295,3912.8,percent of total billed charges,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,AETNA [1000108],AETNA [100010801],,,77.2,,4046.824,1176.829,4193.6,percent of total billed charges,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,AETNA [1000108],AETNA [100010801],,,77.2,,4219.752,1227.117,4372.8,percent of total billed charges,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,AETNA [1000108],AETNA [100010801],,,77.2,,514.924,149.7415,533.6,percent of total billed charges,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,77.2,,272.516,79.2485,282.4,percent of total billed charges,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,AETNA [1000108],AETNA [100010801],,,77.2,,252.444,73.4115,261.6,percent of total billed charges,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,AETNA [1000108],AETNA [100010801],,,77.2,,301.08,87.555,312,percent of total billed charges,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,AETNA [1000108],AETNA [100010801],,,77.2,,545.804,158.7215,565.6,percent of total billed charges,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,AETNA [1000108],AETNA [100010801],,,77.2,,111.168,32.328,122.0544,percent of total billed charges,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,77.2,,202.264,58.819,222.0712,percent of total billed charges,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,AETNA [1000108],AETNA [100010801],,,77.2,,209.984,61.064,230.5472,percent of total billed charges,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,77.2,,236.232,68.697,259.3656,percent of total billed charges,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,AETNA [1000108],AETNA [100010801],,,77.2,,291.044,84.6365,319.5452,percent of total billed charges,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,77.2,,363.612,105.7395,399.2196,percent of total billed charges,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,AETNA [1000108],AETNA [100010801],,,77.2,,378.28,110.005,415.324,percent of total billed charges,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,AETNA [1000108],AETNA [100010801],,,77.2,,724.908,210.8055,795.8964,percent of total billed charges,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,AETNA [1000108],AETNA [100010801],,,77.2,,67.936,19.756,74.5888,percent of total billed charges,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,AETNA [1000108],AETNA [100010801],,,77.2,,73.34,21.3275,80.522,percent of total billed charges,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,AETNA [1000108],AETNA [100010801],,,77.2,,83.376,24.246,91.5408,percent of total billed charges,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,AETNA [1000108],AETNA [100010801],,,77.2,,98.816,28.736,108.4928,percent of total billed charges,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,77.2,,148.996,43.3285,163.5868,percent of total billed charges,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,AETNA [1000108],AETNA [100010801],,,77.2,,150.54,43.7775,165.282,percent of total billed charges,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,AETNA [1000108],AETNA [100010801],,,77.2,,173.7,50.5125,190.71,percent of total billed charges,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,77.2,,275.604,80.1465,302.5932,percent of total billed charges,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,77.2,,275.604,80.1465,302.5932,percent of total billed charges,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,77.2,,275.604,80.1465,302.5932,percent of total billed charges,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,AETNA [1000108],AETNA [100010801],,,77.2,,288.728,83.963,317.0024,percent of total billed charges,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,AETNA [1000108],AETNA [100010801],,,77.2,,305.712,88.902,335.6496,percent of total billed charges,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,AETNA [1000108],AETNA [100010801],,,77.2,,310.344,90.249,340.7352,percent of total billed charges,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,AETNA [1000108],AETNA [100010801],,,77.2,,315.748,91.8205,346.6684,percent of total billed charges,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,77.2,,322.696,93.841,354.2968,percent of total billed charges,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,77.2,,321.924,93.6165,353.4492,percent of total billed charges,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,AETNA [1000108],AETNA [100010801],,,77.2,,344.312,100.127,378.0296,percent of total billed charges,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,AETNA [1000108],AETNA [100010801],,,77.2,,348.172,101.2495,382.2676,percent of total billed charges,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,77.2,,359.752,104.617,394.9816,percent of total billed charges,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,77.2,,359.752,104.617,394.9816,percent of total billed charges,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,AETNA [1000108],AETNA [100010801],,,77.2,,362.84,105.515,398.372,percent of total billed charges,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,AETNA [1000108],AETNA [100010801],,,77.2,,376.736,109.556,413.6288,percent of total billed charges,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,AETNA [1000108],AETNA [100010801],,,77.2,,398.352,115.842,437.3616,percent of total billed charges,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,AETNA [1000108],AETNA [100010801],,,77.2,,400.668,116.5155,439.9044,percent of total billed charges,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,AETNA [1000108],AETNA [100010801],,,77.2,,403.756,117.4135,443.2948,percent of total billed charges,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,77.2,,417.652,121.4545,458.5516,percent of total billed charges,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,77.2,,417.652,121.4545,458.5516,percent of total billed charges,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,AETNA [1000108],AETNA [100010801],,,77.2,,429.232,124.822,471.2656,percent of total billed charges,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,AETNA [1000108],AETNA [100010801],,,77.2,,520.328,151.313,571.2824,percent of total billed charges,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,77.2,,535.768,155.803,588.2344,percent of total billed charges,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,77.2,,535.768,155.803,588.2344,percent of total billed charges,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,77.2,,535.768,155.803,588.2344,percent of total billed charges,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,AETNA [1000108],AETNA [100010801],,,77.2,,542.716,157.8235,595.8628,percent of total billed charges,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,AETNA [1000108],AETNA [100010801],,,77.2,,555.068,161.4155,609.4244,percent of total billed charges,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,AETNA [1000108],AETNA [100010801],,,77.2,,557.384,162.089,611.9672,percent of total billed charges,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,AETNA [1000108],AETNA [100010801],,,77.2,,564.332,164.1095,619.5956,percent of total billed charges,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,AETNA [1000108],AETNA [100010801],,,77.2,,590.58,171.7425,648.414,percent of total billed charges,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,AETNA [1000108],AETNA [100010801],,,77.2,,599.072,174.212,657.7376,percent of total billed charges,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,AETNA [1000108],AETNA [100010801],,,77.2,,599.072,174.212,657.7376,percent of total billed charges,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,77.2,,652.34,189.7025,716.222,percent of total billed charges,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,77.2,,652.34,189.7025,716.222,percent of total billed charges,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,77.2,,652.34,189.7025,716.222,percent of total billed charges,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,AETNA [1000108],AETNA [100010801],,,77.2,,690.94,200.9275,758.602,percent of total billed charges,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,AETNA [1000108],AETNA [100010801],,,77.2,,690.94,200.9275,758.602,percent of total billed charges,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,77.2,,638.444,185.6615,700.9652,percent of total billed charges,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,AETNA [1000108],AETNA [100010801],,,77.2,,724.908,210.8055,795.8964,percent of total billed charges,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,AETNA [1000108],AETNA [100010801],,,77.2,,755.788,219.7855,829.8004,percent of total billed charges,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,AETNA [1000108],AETNA [100010801],,,77.2,,1220.532,354.9345,1340.0556,percent of total billed charges,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,AETNA [1000108],AETNA [100010801],,,77.2,,1220.532,354.9345,1340.0556,percent of total billed charges,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,AETNA [1000108],AETNA [100010801],,,77.2,,876.992,255.032,962.8736,percent of total billed charges,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,AETNA [1000108],AETNA [100010801],,,77.2,,979.668,284.8905,1075.6044,percent of total billed charges,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,AETNA [1000108],AETNA [100010801],,,77.2,,1018.268,296.1155,1117.9844,percent of total billed charges,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,AETNA [1000108],AETNA [100010801],,,77.2,,1080.028,314.0755,1185.7924,percent of total billed charges,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,AETNA [1000108],AETNA [100010801],,,77.2,,1086.976,316.096,1193.4208,percent of total billed charges,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,AETNA [1000108],AETNA [100010801],,,77.2,,1564.844,455.0615,1718.0852,percent of total billed charges,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,AETNA [1000108],AETNA [100010801],,,77.2,,1713.068,498.1655,1880.8244,percent of total billed charges,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,AETNA [1000108],AETNA [100010801],,,77.2,,2008.744,584.149,2205.4552,percent of total billed charges,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,AETNA [1000108],AETNA [100010801],,,77.2,,2271.996,660.7035,2494.4868,percent of total billed charges,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,AETNA [1000108],AETNA [100010801],,,77.2,,4296.18,1249.3425,4716.894,percent of total billed charges,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,AETNA [1000108],AETNA [100010801],,,77.2,,4255.264,1237.444,4671.9712,percent of total billed charges,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,AETNA [1000108],AETNA [100010801],,,77.2,,3180.64,924.94,3492.112,percent of total billed charges,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,AETNA [1000108],AETNA [100010801],,,77.2,,4255.264,1237.444,4671.9712,percent of total billed charges,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,AETNA [1000108],AETNA [100010801],,,77.2,,1041.428,302.8505,1143.4124,percent of total billed charges,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,AETNA [1000108],AETNA [100010801],,,77.2,,30.108,8.7555,33.0564,percent of total billed charges,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,AETNA [1000108],AETNA [100010801],,,77.2,,955.736,277.931,1049.3288,percent of total billed charges,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,AETNA [1000108],AETNA [100010801],,,77.2,,859.236,249.8685,943.3788,percent of total billed charges,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,AETNA [1000108],AETNA [100010801],,,77.2,,1456.764,423.6315,1599.4212,percent of total billed charges,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,AETNA [1000108],AETNA [100010801],,,77.2,,846.884,246.2765,929.8172,percent of total billed charges,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,AETNA [1000108],AETNA [100010801],,,77.2,,1161.088,337.648,1274.7904,percent of total billed charges,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,AETNA [1000108],AETNA [100010801],,,77.2,,246.268,71.6155,270.3844,percent of total billed charges,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,AETNA [1000108],AETNA [100010801],,,77.2,,356.664,103.719,391.5912,percent of total billed charges,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,AETNA [1000108],AETNA [100010801],,,77.2,,831.444,241.7865,912.8652,percent of total billed charges,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,77.2,,375.192,109.107,411.9336,percent of total billed charges,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,77.2,,345.084,100.3515,378.8772,percent of total billed charges,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,AETNA [1000108],AETNA [100010801],,,77.2,,1028.304,299.034,1129.0032,percent of total billed charges,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,AETNA [1000108],AETNA [100010801],,,77.2,,229.284,66.6765,251.7372,percent of total billed charges,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,AETNA [1000108],AETNA [100010801],,,77.2,,414.564,120.5565,455.1612,percent of total billed charges,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,AETNA [1000108],AETNA [100010801],,,77.2,,436.18,126.8425,478.894,percent of total billed charges,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,77.2,,321.924,93.6165,353.4492,percent of total billed charges,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,77.2,,318.064,92.494,349.2112,percent of total billed charges,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,AETNA [1000108],AETNA [100010801],,,77.2,,533.452,155.1295,585.6916,percent of total billed charges,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,AETNA [1000108],AETNA [100010801],,,77.2,,390.632,113.597,428.8856,percent of total billed charges,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,AETNA [1000108],AETNA [100010801],,,77.2,,327.328,95.188,359.3824,percent of total billed charges,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,AETNA [1000108],AETNA [100010801],,,77.2,,458.568,133.353,503.4744,percent of total billed charges,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,77.2,,408.388,118.7605,448.3804,percent of total billed charges,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,AETNA [1000108],AETNA [100010801],,,77.2,,699.432,203.397,767.9256,percent of total billed charges,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,AETNA [1000108],AETNA [100010801],,,77.2,,500.256,145.476,549.2448,percent of total billed charges,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,AETNA [1000108],AETNA [100010801],,,77.2,,764.28,222.255,839.124,percent of total billed charges,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,AETNA [1000108],AETNA [100010801],,,77.2,,667.78,194.1925,733.174,percent of total billed charges,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,AETNA [1000108],AETNA [100010801],,,77.2,,334.276,97.2085,367.0108,percent of total billed charges,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,77.2,,304.168,88.453,333.9544,percent of total billed charges,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,AETNA [1000108],AETNA [100010801],,,77.2,,467.832,136.047,513.6456,percent of total billed charges,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,AETNA [1000108],AETNA [100010801],,,77.2,,540.4,157.15,593.32,percent of total billed charges,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,AETNA [1000108],AETNA [100010801],,,77.2,,1702.26,495.0225,1868.958,percent of total billed charges,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,AETNA [1000108],AETNA [100010801],,,77.2,,1031.392,299.932,1132.3936,percent of total billed charges,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,AETNA [1000108],AETNA [100010801],,,77.2,,844.568,245.603,927.2744,percent of total billed charges,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,AETNA [1000108],AETNA [100010801],,,77.2,,917.136,266.706,1006.9488,percent of total billed charges,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,77.2,,890.888,259.073,978.1304,percent of total billed charges,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,77.2,,890.888,259.073,978.1304,percent of total billed charges,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,AETNA [1000108],AETNA [100010801],,,77.2,,606.02,176.2325,665.366,percent of total billed charges,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,77.2,,601.388,174.8855,660.2804,percent of total billed charges,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,AETNA [1000108],AETNA [100010801],,,77.2,,919.452,267.3795,1009.4916,percent of total billed charges,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,AETNA [1000108],AETNA [100010801],,,77.2,,758.876,220.6835,833.1908,percent of total billed charges,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,AETNA [1000108],AETNA [100010801],,,77.2,,352.804,102.5965,387.3532,percent of total billed charges,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,77.2,,363.612,105.7395,399.2196,percent of total billed charges,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,AETNA [1000108],AETNA [100010801],,,77.2,,358.98,104.3925,394.134,percent of total billed charges,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,AETNA [1000108],AETNA [100010801],,,77.2,,635.356,184.7635,697.5748,percent of total billed charges,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,AETNA [1000108],AETNA [100010801],,,77.2,,477.868,138.9655,524.6644,percent of total billed charges,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,AETNA [1000108],AETNA [100010801],,,77.2,,613.74,178.4775,673.842,percent of total billed charges,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,AETNA [1000108],AETNA [100010801],,,77.2,,557.384,162.089,611.9672,percent of total billed charges,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,AETNA [1000108],AETNA [100010801],,,77.2,,189.14,55.0025,207.662,percent of total billed charges,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,AETNA [1000108],AETNA [100010801],,,77.2,,736.488,214.173,808.6104,percent of total billed charges,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,77.2,,890.888,259.073,978.1304,percent of total billed charges,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,AETNA [1000108],AETNA [100010801],,,77.2,,383.684,111.5765,421.2572,percent of total billed charges,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,AETNA [1000108],AETNA [100010801],,,77.2,,193.772,56.3495,212.7476,percent of total billed charges,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,AETNA [1000108],AETNA [100010801],,,77.2,,314.976,91.596,345.8208,percent of total billed charges,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,77.2,,345.084,100.3515,378.8772,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,AETNA [1000108],AETNA [100010801],,,77.2,,277.148,80.5955,304.2884,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,77.2,,240.864,70.044,264.4512,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,77.2,,240.864,70.044,264.4512,percent of total billed charges,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,AETNA [1000108],AETNA [100010801],,,77.2,,480.184,139.639,527.2072,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,AETNA [1000108],AETNA [100010801],,,77.2,,426.144,123.924,467.8752,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,AETNA [1000108],AETNA [100010801],,,77.2,,942.612,274.1145,1034.9196,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,AETNA [1000108],AETNA [100010801],,,77.2,,2911.984,846.814,3197.1472,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,AETNA [1000108],AETNA [100010801],,,77.2,,1508.488,438.673,1656.2104,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,AETNA [1000108],AETNA [100010801],,,77.2,,2938.232,854.447,3225.9656,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,AETNA [1000108],AETNA [100010801],,,77.2,,510.292,148.3945,560.2636,percent of total billed charges,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,AETNA [1000108],AETNA [100010801],,,77.2,,440.04,127.965,483.132,percent of total billed charges,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,AETNA [1000108],AETNA [100010801],,,77.2,,440.04,127.965,483.132,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,AETNA [1000108],AETNA [100010801],,,77.2,,2613.22,759.9325,2869.126,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,AETNA [1000108],AETNA [100010801],,,77.2,,2458.82,715.0325,2699.606,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,AETNA [1000108],AETNA [100010801],,,77.2,,293.36,85.31,322.088,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,77.2,,601.388,174.8855,660.2804,percent of total billed charges,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,AETNA [1000108],AETNA [100010801],,,77.2,,254.76,74.085,279.708,percent of total billed charges,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,AETNA [1000108],AETNA [100010801],,,77.2,,294.904,85.759,323.7832,percent of total billed charges,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,77.2,,345.856,100.576,379.7248,percent of total billed charges,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,AETNA [1000108],AETNA [100010801],,,77.2,,365.156,106.1885,400.9148,percent of total billed charges,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,77.2,,387.544,112.699,425.4952,percent of total billed charges,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,77.2,,507.976,147.721,557.7208,percent of total billed charges,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,AETNA [1000108],AETNA [100010801],,,77.2,,510.292,148.3945,560.2636,percent of total billed charges,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,AETNA [1000108],AETNA [100010801],,,77.2,,542.716,157.8235,595.8628,percent of total billed charges,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,AETNA [1000108],AETNA [100010801],,,77.2,,575.14,167.2525,631.462,percent of total billed charges,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,AETNA [1000108],AETNA [100010801],,,77.2,,606.02,176.2325,665.366,percent of total billed charges,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,AETNA [1000108],AETNA [100010801],,,77.2,,695.572,202.2745,763.6876,percent of total billed charges,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,77.2,,706.38,205.4175,775.554,percent of total billed charges,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,AETNA [1000108],AETNA [100010801],,,77.2,,862.324,250.7665,946.7692,percent of total billed charges,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,AETNA [1000108],AETNA [100010801],,,77.2,,1976.32,574.72,2169.856,percent of total billed charges,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,AETNA [1000108],AETNA [100010801],,,77.2,,1976.32,574.72,2169.856,percent of total billed charges,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,77.2,,2295.928,667.663,2520.7624,percent of total billed charges,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,AETNA [1000108],AETNA [100010801],,,77.2,,2324.492,675.9695,2552.1236,percent of total billed charges,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,AETNA [1000108],AETNA [100010801],,,77.2,,2324.492,675.9695,2552.1236,percent of total billed charges,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,AETNA [1000108],AETNA [100010801],,,77.2,,2443.38,710.5425,2682.654,percent of total billed charges,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,AETNA [1000108],AETNA [100010801],,,77.2,,2638.696,767.341,2897.0968,percent of total billed charges,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,AETNA [1000108],AETNA [100010801],,,77.2,,2672.664,777.219,2934.3912,percent of total billed charges,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,AETNA [1000108],AETNA [100010801],,,77.2,,5092.884,1481.0265,5591.6172,percent of total billed charges,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,77.2,,507.976,147.721,557.7208,percent of total billed charges,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,77.2,,507.976,147.721,557.7208,percent of total billed charges,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,AETNA [1000108],AETNA [100010801],,,77.2,,951.104,276.584,1044.2432,percent of total billed charges,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,AETNA [1000108],AETNA [100010801],,,77.2,,1351,392.875,1483.3,percent of total billed charges,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,AETNA [1000108],AETNA [100010801],,,77.2,,3036.276,882.9585,3333.6108,percent of total billed charges,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,AETNA [1000108],AETNA [100010801],,,77.2,,3176.008,923.593,3487.0264,percent of total billed charges,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,AETNA [1000108],AETNA [100010801],,,77.2,,3443.892,1001.4945,3781.1436,percent of total billed charges,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,77.2,,359.752,104.617,394.9816,percent of total billed charges,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,77.2,,2295.928,667.663,2520.7624,percent of total billed charges,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,77.2,,2295.928,667.663,2520.7624,percent of total billed charges,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,77.2,,2295.928,667.663,2520.7624,percent of total billed charges,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,77.2,,819.864,238.419,900.1512,percent of total billed charges,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,77.2,,819.864,238.419,900.1512,percent of total billed charges,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,77.2,,819.864,238.419,900.1512,percent of total billed charges,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,AETNA [1000108],AETNA [100010801],,,77.2,,1115.54,324.4025,1224.782,percent of total billed charges,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,77.2,,345.856,100.576,379.7248,percent of total billed charges,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,77.2,,267.884,77.9015,294.1172,percent of total billed charges,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,AETNA [1000108],AETNA [100010801],,,77.2,,822.18,239.0925,902.694,percent of total billed charges,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,77.2,,272.516,79.2485,299.2028,percent of total billed charges,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,AETNA [1000108],AETNA [100010801],,,77.2,,1090.836,317.2185,1197.6588,percent of total billed charges,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,AETNA [1000108],AETNA [100010801],,,77.2,,995.88,289.605,1093.404,percent of total billed charges,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,AETNA [1000108],AETNA [100010801],,,77.2,,995.88,289.605,1093.404,percent of total billed charges,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,AETNA [1000108],AETNA [100010801],,,77.2,,1648.22,479.3075,1809.626,percent of total billed charges,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,AETNA [1000108],AETNA [100010801],,,77.2,,575.14,167.2525,631.462,percent of total billed charges,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,77.2,,202.264,58.819,222.0712,percent of total billed charges,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,77.2,,202.264,58.819,222.0712,percent of total billed charges,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,77.2,,272.516,79.2485,299.2028,percent of total billed charges,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,AETNA [1000108],AETNA [100010801],,,77.2,,992.792,288.707,1090.0136,percent of total billed charges,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,AETNA [1000108],AETNA [100010801],,,77.2,,501.028,145.7005,550.0924,percent of total billed charges,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,AETNA [1000108],AETNA [100010801],,,77.2,,585.176,170.171,642.4808,percent of total billed charges,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,AETNA [1000108],AETNA [100010801],,,77.2,,820.636,238.6435,900.9988,percent of total billed charges,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,AETNA [1000108],AETNA [100010801],,,77.2,,843.796,245.3785,926.4268,percent of total billed charges,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,AETNA [1000108],AETNA [100010801],,,77.2,,939.524,273.2165,1031.5292,percent of total billed charges,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,AETNA [1000108],AETNA [100010801],,,77.2,,1046.06,304.1975,1148.498,percent of total billed charges,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,AETNA [1000108],AETNA [100010801],,,77.2,,1079.256,313.851,1184.9448,percent of total billed charges,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,AETNA [1000108],AETNA [100010801],,,77.2,,1137.928,330.913,1249.3624,percent of total billed charges,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,AETNA [1000108],AETNA [100010801],,,77.2,,1157.228,336.5255,1270.5524,percent of total billed charges,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,AETNA [1000108],AETNA [100010801],,,77.2,,1368.756,398.0385,1502.7948,percent of total billed charges,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,AETNA [1000108],AETNA [100010801],,,77.2,,1223.62,355.8325,1343.446,percent of total billed charges,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,AETNA [1000108],AETNA [100010801],,,77.2,,1262.992,367.282,1386.6736,percent of total billed charges,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,AETNA [1000108],AETNA [100010801],,,77.2,,1350.228,392.6505,1482.4524,percent of total billed charges,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,77.2,,365.928,106.413,401.7624,percent of total billed charges,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,77.2,,365.928,106.413,401.7624,percent of total billed charges,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,77.2,,365.928,106.413,401.7624,percent of total billed charges,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,AETNA [1000108],AETNA [100010801],,,77.2,,253.216,73.636,278.0128,percent of total billed charges,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,77.2,,375.192,109.107,411.9336,percent of total billed charges,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,AETNA [1000108],AETNA [100010801],,,77.2,,1368.756,398.0385,1502.7948,percent of total billed charges,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,77.2,,535.768,155.803,588.2344,percent of total billed charges,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,77.2,,365.928,106.413,401.7624,percent of total billed charges,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,AETNA [1000108],AETNA [100010801],,,77.2,,366.7,106.6375,402.61,percent of total billed charges,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,AETNA [1000108],AETNA [100010801],,,77.2,,1320.12,383.895,1449.396,percent of total billed charges,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,AETNA [1000108],AETNA [100010801],,,77.2,,1024.444,297.9115,1124.7652,percent of total billed charges,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,AETNA [1000108],AETNA [100010801],,,77.2,,1024.444,297.9115,1124.7652,percent of total billed charges,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,AETNA [1000108],AETNA [100010801],,,77.2,,1003.6,291.85,1101.88,percent of total billed charges,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,AETNA [1000108],AETNA [100010801],,,77.2,,24.704,7.184,27.1232,percent of total billed charges,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,AETNA [1000108],AETNA [100010801],,,77.2,,109.624,31.879,120.3592,percent of total billed charges,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,AETNA [1000108],AETNA [100010801],,,77.2,,121.204,35.2465,133.0732,percent of total billed charges,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,AETNA [1000108],AETNA [100010801],,,77.2,,117.344,34.124,128.8352,percent of total billed charges,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,AETNA [1000108],AETNA [100010801],,,77.2,,160.576,46.696,176.3008,percent of total billed charges,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,77.2,,46.32,13.47,50.856,percent of total billed charges,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,AETNA [1000108],AETNA [100010801],,,77.2,,57.9,16.8375,63.57,percent of total billed charges,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,77.2,,46.32,13.47,50.856,percent of total billed charges,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,AETNA [1000108],AETNA [100010801],,,77.2,,57.9,16.8375,63.57,percent of total billed charges,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,AETNA [1000108],AETNA [100010801],,,77.2,,76.428,22.2255,83.9124,percent of total billed charges,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,AETNA [1000108],AETNA [100010801],,,77.2,,108.08,31.43,118.664,percent of total billed charges,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,AETNA [1000108],AETNA [100010801],,,77.2,,106.536,30.981,116.9688,percent of total billed charges,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,77.2,,122.748,35.6955,134.7684,percent of total billed charges,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,AETNA [1000108],AETNA [100010801],,,77.2,,540.4,157.15,593.32,percent of total billed charges,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,AETNA [1000108],AETNA [100010801],,,77.2,,656.2,190.825,720.46,percent of total billed charges,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,AETNA [1000108],AETNA [100010801],,,77.2,,1283.064,373.119,1408.7112,percent of total billed charges,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,77.2,,733.4,213.275,805.22,percent of total billed charges,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,AETNA [1000108],AETNA [100010801],,,77.2,,2257.328,656.438,2478.3824,percent of total billed charges,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,77.2,,926.4,269.4,1017.12,percent of total billed charges,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,AETNA [1000108],AETNA [100010801],,,77.2,,3290.264,956.819,3612.4712,percent of total billed charges,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,AETNA [1000108],AETNA [100010801],,,77.2,,7076.152,2057.767,7769.1016,percent of total billed charges,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,77.2,,926.4,269.4,1017.12,percent of total billed charges,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,AETNA [1000108],AETNA [100010801],,,77.2,,2894.228,841.6505,3177.6524,percent of total billed charges,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,AETNA [1000108],AETNA [100010801],,,77.2,,4134.832,1202.422,4539.7456,percent of total billed charges,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,AETNA [1000108],AETNA [100010801],,,77.2,,7442.852,2164.4045,8171.7116,percent of total billed charges,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,AETNA [1000108],AETNA [100010801],,,77.2,,19.3,5.6125,21.19,percent of total billed charges,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,AETNA [1000108],AETNA [100010801],,,77.2,,16.984,4.939,18.6472,percent of total billed charges,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,AETNA [1000108],AETNA [100010801],,,77.2,,17.756,5.1635,19.4948,percent of total billed charges,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,AETNA [1000108],AETNA [100010801],,,77.2,,21.616,6.286,23.7328,percent of total billed charges,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,77.2,,22.388,6.5105,24.5804,percent of total billed charges,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,AETNA [1000108],AETNA [100010801],,,77.2,,25.476,7.4085,27.9708,percent of total billed charges,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,AETNA [1000108],AETNA [100010801],,,77.2,,29.336,8.531,32.2088,percent of total billed charges,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,AETNA [1000108],AETNA [100010801],,,77.2,,1158,336.75,1271.4,percent of total billed charges,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,AETNA [1000108],AETNA [100010801],,,77.2,,77.972,22.6745,6652,percent of total billed charges,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,AETNA [1000108],AETNA [100010801],,,77.2,,439.268,127.7405,482.2844,percent of total billed charges,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,AETNA [1000108],AETNA [100010801],,,77.2,,439.268,127.7405,482.2844,percent of total billed charges,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,77.2,,22.388,6.5105,24.5804,percent of total billed charges,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,AETNA [1000108],AETNA [100010801],,,77.2,,5.404,1.5715,163,percent of total billed charges,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,AETNA [1000108],AETNA [100010801],,,77.2,,33.196,9.6535,163,percent of total billed charges,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,AETNA [1000108],AETNA [100010801],,,77.2,,132.012,38.3895,163,percent of total billed charges,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,AETNA [1000108],AETNA [100010801],,,77.2,,8005.64,399.86,9291.52,percent of total billed charges,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,AETNA [1000108],AETNA [100010801],,,77.2,,5426.388,399.86,6297.984,percent of total billed charges,
Heart Transplant Or Implant Of Heart Assist System With McC,1,MS-DRG,,,,,,,inpatient,,,509415.58,356590.906,AETNA [1000108],AETNA [100010801],,,77.2,,393268.8278,7771.48,570763.9296,percent of total billed charges,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,495073.43,346551.401,AETNA [1000108],AETNA [100010801],,,77.2,,382196.688,7771.48,434261.5728,percent of total billed charges,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,347238.19,243066.733,AETNA [1000108],AETNA [100010801],,,77.2,,268067.8827,7771.48,286312.0824,percent of total billed charges,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,111379.6,77965.72,AETNA [1000108],AETNA [100010801],,,77.2,,85985.0512,7771.48,109336.4384,percent of total billed charges,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,80508.95,56356.265,AETNA [1000108],AETNA [100010801],,,77.2,,62152.9094,7771.48,90620.608,percent of total billed charges,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,64638.3,45246.81,AETNA [1000108],AETNA [100010801],,,77.2,,49900.7676,7771.48,123186.8824,percent of total billed charges,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,31748.36,22223.852,AETNA [1000108],AETNA [100010801],,,77.2,,24509.73392,7771.48,68016.116,percent of total billed charges,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,38853.43,27197.401,AETNA [1000108],AETNA [100010801],,,77.2,,29994.84796,7771.48,45091.4528,percent of total billed charges,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,36305.14,25413.598,AETNA [1000108],AETNA [100010801],,,77.2,,28027.56808,7771.48,32329.1856,percent of total billed charges,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,66447.77,46513.439,AETNA [1000108],AETNA [100010801],,,77.2,,51297.67844,7771.48,78796.564,percent of total billed charges,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,67076.27,46953.389,AETNA [1000108],AETNA [100010801],,,77.2,,51782.88044,7771.48,53661.016,percent of total billed charges,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,60360.78,42252.546,AETNA [1000108],AETNA [100010801],,,77.2,,46598.52216,7771.48,48288.624,percent of total billed charges,
Extracranial Procedures With McC,37,MS-DRG,,,,,,,inpatient,,,89958.63,62971.041,AETNA [1000108],AETNA [100010801],,,77.2,,69448.06236,7771.48,71966.904,percent of total billed charges,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,41578.78,29105.146,AETNA [1000108],AETNA [100010801],,,77.2,,32098.81816,7771.48,33263.024,percent of total billed charges,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,33795.18,23656.626,AETNA [1000108],AETNA [100010801],,,77.2,,26089.87896,7771.48,27036.144,percent of total billed charges,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,68215.86,47751.102,AETNA [1000108],AETNA [100010801],,,77.2,,52662.64392,7771.48,54572.688,percent of total billed charges,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,26930.4,18851.28,AETNA [1000108],AETNA [100010801],,,77.2,,20790.2688,7771.48,30377.7624,percent of total billed charges,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,21358.75,14951.125,AETNA [1000108],AETNA [100010801],,,77.2,,16488.955,7123.143125,22105.9976,percent of total billed charges,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,44783.08,31348.156,AETNA [1000108],AETNA [100010801],,,77.2,,34572.53776,7771.48,50741.056,percent of total billed charges,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,47305.96,33114.172,AETNA [1000108],AETNA [100010801],,,77.2,,36520.20112,7771.48,37844.768,percent of total billed charges,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,15006.39,10504.473,AETNA [1000108],AETNA [100010801],,,77.2,,11584.93308,5004.631065,37401.2648,percent of total billed charges,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,24159.04,16911.328,AETNA [1000108],AETNA [100010801],,,77.2,,18650.77888,7771.48,24793.004,percent of total billed charges,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,28159.44,19711.608,AETNA [1000108],AETNA [100010801],,,77.2,,21739.08768,6624.72,22527.552,percent of total billed charges,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,89978.5,62984.95,AETNA [1000108],AETNA [100010801],,,77.2,,69463.402,7771.48,71982.8,percent of total billed charges,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,41764.16,29234.912,AETNA [1000108],AETNA [100010801],,,77.2,,32241.93152,7771.48,36086.1312,percent of total billed charges,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,42817.54,29972.278,AETNA [1000108],AETNA [100010801],,,77.2,,33055.14088,7771.48,34254.032,percent of total billed charges,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,29171.68,20420.176,AETNA [1000108],AETNA [100010801],,,77.2,,22520.53696,7771.48,40307.1224,percent of total billed charges,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20113.63,14079.541,AETNA [1000108],AETNA [100010801],,,77.2,,15527.72236,6707.895605,20608.488,percent of total billed charges,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,15729.11,11010.377,AETNA [1000108],AETNA [100010801],,,77.2,,12142.87292,5143.64,13947.7112,percent of total billed charges,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,46442.5,32509.75,AETNA [1000108],AETNA [100010801],,,77.2,,35853.61,7771.48,37154,percent of total billed charges,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,28051.55,19636.085,AETNA [1000108],AETNA [100010801],,,77.2,,21655.7966,6429.37,22441.24,percent of total billed charges,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17263.03,12084.121,AETNA [1000108],AETNA [100010801],,,77.2,,13327.05916,5687.74,16215.2528,percent of total billed charges,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,34983.65,24488.555,AETNA [1000108],AETNA [100010801],,,77.2,,27007.3778,7771.48,35233.0168,percent of total billed charges,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,19683.37,13778.359,AETNA [1000108],AETNA [100010801],,,77.2,,15195.56164,6564.403895,21354.2032,percent of total billed charges,
Nonspecific Cerebrovascular Disorders Without Cc/McC,72,MS-DRG,,,,,,,inpatient,,,12084.89,8459.423,AETNA [1000108],AETNA [100010801],,,77.2,,9329.53508,4030.310815,15200.0264,percent of total billed charges,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,16388.09,11471.663,AETNA [1000108],AETNA [100010801],,,77.2,,12651.60548,5465.428015,31318.012,percent of total billed charges,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,28055.14,19638.598,AETNA [1000108],AETNA [100010801],,,77.2,,21658.56808,7368.52,22444.112,percent of total billed charges,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,26116.94,18281.858,AETNA [1000108],AETNA [100010801],,,77.2,,20162.27768,7097.19,20893.552,percent of total billed charges,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,23235.5,16264.85,AETNA [1000108],AETNA [100010801],,,77.2,,17937.806,7749.03925,31332.1968,percent of total billed charges,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,15869.98,11108.986,AETNA [1000108],AETNA [100010801],,,77.2,,12251.62456,5292.63833,20219.4192,percent of total billed charges,
Hypertensive Encephalopathy Without Cc/McC,79,MS-DRG,,,,,,,inpatient,,,15211.5,10648.05,AETNA [1000108],AETNA [100010801],,,77.2,,11743.278,5073.03525,13510.0088,percent of total billed charges,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,53186.54,37230.578,AETNA [1000108],AETNA [100010801],,,77.2,,41060.00888,7771.48,42549.232,percent of total billed charges,
Nontraumatic Stupor And Coma Without McC,81,MS-DRG,,,,,,,inpatient,,,72271.24,50589.868,AETNA [1000108],AETNA [100010801],,,77.2,,55793.39728,5585.72,57816.992,percent of total billed charges,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,28572.47,20000.729,AETNA [1000108],AETNA [100010801],,,77.2,,22057.94684,7771.48,47014.5064,percent of total billed charges,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,30376.08,21263.256,AETNA [1000108],AETNA [100010801],,,77.2,,23450.33376,7771.48,28173.0392,percent of total billed charges,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,15324.04,10726.828,AETNA [1000108],AETNA [100010801],,,77.2,,11830.15888,5110.56734,19372.384,percent of total billed charges,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,40898.43,28628.901,AETNA [1000108],AETNA [100010801],,,77.2,,31573.58796,7771.48,45916.1976,percent of total billed charges,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,13317.55,9322.285,AETNA [1000108],AETNA [100010801],,,77.2,,10281.1486,4441.402925,26578.2624,percent of total billed charges,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,24255.02,16978.514,AETNA [1000108],AETNA [100010801],,,77.2,,18724.87544,6241.25,19404.016,percent of total billed charges,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,42230.83,29561.581,AETNA [1000108],AETNA [100010801],,,77.2,,32602.20076,7771.48,36937.2192,percent of total billed charges,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,30155.68,21108.976,AETNA [1000108],AETNA [100010801],,,77.2,,23280.18496,7134.82,24124.544,percent of total billed charges,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,16152.97,11307.079,AETNA [1000108],AETNA [100010801],,,77.2,,12470.09284,5387.015495,15994.3752,percent of total billed charges,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,56481.63,39537.141,AETNA [1000108],AETNA [100010801],,,77.2,,43603.81836,7771.48,73931.1776,percent of total billed charges,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,49973.83,34981.681,AETNA [1000108],AETNA [100010801],,,77.2,,38579.79676,7771.48,72642.3872,percent of total billed charges,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,15617.77,10932.439,AETNA [1000108],AETNA [100010801],,,77.2,,12056.91844,5208.526295,43954.6424,percent of total billed charges,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC,99,MS-DRG,,,,,,,inpatient,,,27081.74,18957.218,AETNA [1000108],AETNA [100010801],,,77.2,,20907.10328,7771.48,28231.8048,percent of total billed charges,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,34012.87,23809.009,AETNA [1000108],AETNA [100010801],,,77.2,,26257.93564,7771.48,40228.0928,percent of total billed charges,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,18803.33,13162.331,AETNA [1000108],AETNA [100010801],,,77.2,,14516.17076,6270.910555,18675.3024,percent of total billed charges,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,27377.14,19163.998,AETNA [1000108],AETNA [100010801],,,77.2,,21135.15208,7771.48,23494.0816,percent of total billed charges,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,23893.76,16725.632,AETNA [1000108],AETNA [100010801],,,77.2,,18445.98272,5992.35,19115.008,percent of total billed charges,
Acute Major Eye Infections With Cc/McC,121,MS-DRG,,,,,,,inpatient,,,20815.14,14570.598,AETNA [1000108],AETNA [100010801],,,77.2,,16069.28808,6941.84919,23569.0584,percent of total billed charges,
Acute Major Eye Infections Without Cc/McC,122,MS-DRG,,,,,,,inpatient,,,8234.57,5764.199,AETNA [1000108],AETNA [100010801],,,77.2,,6357.08804,2746.229095,13745.0712,percent of total billed charges,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,28026.78,19618.746,AETNA [1000108],AETNA [100010801],,,77.2,,21636.67416,5537.24,22421.424,percent of total billed charges,
Other Disorders Of The Eye With McC Or Thrombolytic Agent,124,MS-DRG,,,,,,,inpatient,,,12298.33,8608.831,AETNA [1000108],AETNA [100010801],,,77.2,,9494.31076,4101.493055,26420.2032,percent of total billed charges,
Other Disorders Of The Eye Without McC,125,MS-DRG,,,,,,,inpatient,,,18740.93,13118.651,AETNA [1000108],AETNA [100010801],,,77.2,,14467.99796,6044.44,16731.9848,percent of total billed charges,
Mouth Procedures With Cc/McC,137,MS-DRG,,,,,,,inpatient,,,29533.69,20673.583,AETNA [1000108],AETNA [100010801],,,77.2,,22800.00868,7771.48,28339.204,percent of total billed charges,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,44941.05,31458.735,AETNA [1000108],AETNA [100010801],,,77.2,,34694.4906,7771.48,66905.6488,percent of total billed charges,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,9316.44,6521.508,AETNA [1000108],AETNA [100010801],,,77.2,,7192.29168,3107.03274,35595.7424,percent of total billed charges,
Ear- Nose- Mouth And Throat Malignancy With McC,146,MS-DRG,,,,,,,inpatient,,,13156.92,9209.844,AETNA [1000108],AETNA [100010801],,,77.2,,10157.14224,4387.83282,46483.5896,percent of total billed charges,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,13619.01,9533.307,AETNA [1000108],AETNA [100010801],,,77.2,,10513.87572,4541.939835,15147.34,percent of total billed charges,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,14296.01,10007.207,AETNA [1000108],AETNA [100010801],,,77.2,,11036.51972,4767.719335,15360.112,percent of total billed charges,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,12866.36,9006.452,AETNA [1000108],AETNA [100010801],,,77.2,,9932.82992,4290.93106,22993.5608,percent of total billed charges,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,16420.88,11494.616,AETNA [1000108],AETNA [100010801],,,77.2,,12676.91936,5141.47,14421.8888,percent of total billed charges,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,12009,8406.3,AETNA [1000108],AETNA [100010801],,,77.2,,9270.948,4005.0015,32953.3168,percent of total billed charges,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,39912.51,27938.757,AETNA [1000108],AETNA [100010801],,,77.2,,30812.45772,6561.05,31930.008,percent of total billed charges,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,11067.63,7747.341,AETNA [1000108],AETNA [100010801],,,77.2,,8544.21036,3691.054605,13625.5136,percent of total billed charges,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,32953.66,23067.562,AETNA [1000108],AETNA [100010801],,,77.2,,25440.22552,7771.48,33180.2736,percent of total billed charges,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,27223.03,19056.121,AETNA [1000108],AETNA [100010801],,,77.2,,21016.17916,6432.99,21778.424,percent of total billed charges,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,2839.79,1987.853,AETNA [1000108],AETNA [100010801],,,77.2,,2192.31788,947.069965,13366.1344,percent of total billed charges,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,115551.53,80886.071,AETNA [1000108],AETNA [100010801],,,77.2,,89205.78116,7771.48,93394.7496,percent of total billed charges,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,85038.13,59526.691,AETNA [1000108],AETNA [100010801],,,77.2,,65649.43636,7771.48,68030.504,percent of total billed charges,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,69826.08,48878.256,AETNA [1000108],AETNA [100010801],,,77.2,,53905.73376,7771.48,55860.864,percent of total billed charges,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,55683.12,38978.184,AETNA [1000108],AETNA [100010801],,,77.2,,42987.36864,7771.48,78036.664,percent of total billed charges,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,45649.7,31954.79,AETNA [1000108],AETNA [100010801],,,77.2,,35241.5684,7771.48,37024.3544,percent of total billed charges,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,47015.57,32910.899,AETNA [1000108],AETNA [100010801],,,77.2,,36296.02004,7771.48,37612.456,percent of total billed charges,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,78265.02,54785.514,AETNA [1000108],AETNA [100010801],,,77.2,,60420.59544,7771.48,62612.016,percent of total billed charges,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,20842.72,14589.904,AETNA [1000108],AETNA [100010801],,,77.2,,16090.57984,6951.04712,28554.0024,percent of total billed charges,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,18317.47,12822.229,AETNA [1000108],AETNA [100010801],,,77.2,,14141.08684,6108.876245,16505.028,percent of total billed charges,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,31259.62,21881.734,AETNA [1000108],AETNA [100010801],,,77.2,,24132.42664,7771.48,32756.756,percent of total billed charges,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,20969.38,14678.566,AETNA [1000108],AETNA [100010801],,,77.2,,16188.36136,6993.28823,20103.9144,percent of total billed charges,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20162.41,14113.687,AETNA [1000108],AETNA [100010801],,,77.2,,15565.38052,6302.75,16129.928,percent of total billed charges,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,37050.11,25935.077,AETNA [1000108],AETNA [100010801],,,77.2,,28602.68492,7771.48,35415.3928,percent of total billed charges,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,30930.47,21651.329,AETNA [1000108],AETNA [100010801],,,77.2,,23878.32284,7771.48,24744.376,percent of total billed charges,
Respiratory Neoplasms Without Cc/McC,182,MS-DRG,,,,,,,inpatient,,,24638.57,17246.999,AETNA [1000108],AETNA [100010801],,,77.2,,19020.97604,5697.87,19710.856,percent of total billed charges,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,35855.45,25098.815,AETNA [1000108],AETNA [100010801],,,77.2,,27680.4074,7771.48,32163.0208,percent of total billed charges,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,22588.59,15812.013,AETNA [1000108],AETNA [100010801],,,77.2,,17438.39148,7520.46,21641.952,percent of total billed charges,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,25741.06,18018.742,AETNA [1000108],AETNA [100010801],,,77.2,,19872.09832,7771.48,32017.12,percent of total billed charges,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,11443.72,8010.604,AETNA [1000108],AETNA [100010801],,,77.2,,8834.55184,3816.48062,20343.0296,percent of total billed charges,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,21611.05,15127.735,AETNA [1000108],AETNA [100010801],,,77.2,,16683.7306,7207.285175,25076.7,percent of total billed charges,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,22710.76,15897.532,AETNA [1000108],AETNA [100010801],,,77.2,,17532.70672,7574.03846,22762.5512,percent of total billed charges,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,17567.6,12297.32,AETNA [1000108],AETNA [100010801],,,77.2,,13562.1872,5858.7946,17408.8024,percent of total billed charges,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,13024.23,9116.961,AETNA [1000108],AETNA [100010801],,,77.2,,10054.70556,4343.580705,13114.8608,percent of total billed charges,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,25981.01,18186.707,AETNA [1000108],AETNA [100010801],,,77.2,,20057.33972,7771.48,26703.8992,percent of total billed charges,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,18230.9,12761.63,AETNA [1000108],AETNA [100010801],,,77.2,,14074.2548,6080.00515,16616.48,percent of total billed charges,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,12094.06,8465.842,AETNA [1000108],AETNA [100010801],,,77.2,,9336.61432,4033.36901,12620.4192,percent of total billed charges,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25422.94,17796.058,AETNA [1000108],AETNA [100010801],,,77.2,,19626.50968,7771.48,38181.4288,percent of total billed charges,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,23032.67,16122.869,AETNA [1000108],AETNA [100010801],,,77.2,,17781.22124,7275.91,20059.3336,percent of total billed charges,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,22301.78,15611.246,AETNA [1000108],AETNA [100010801],,,77.2,,17216.97416,7437.64363,35770.0128,percent of total billed charges,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,31940.04,22358.028,AETNA [1000108],AETNA [100010801],,,77.2,,24657.71088,7771.48,25552.032,percent of total billed charges,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,17352.2,12146.54,AETNA [1000108],AETNA [100010801],,,77.2,,13395.8984,5133.51,13881.76,percent of total billed charges,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,17596.96,12317.872,AETNA [1000108],AETNA [100010801],,,77.2,,13584.85312,5868.58616,19589.2088,percent of total billed charges,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,12229.54,8560.678,AETNA [1000108],AETNA [100010801],,,77.2,,9441.20488,4078.55159,14109.8232,percent of total billed charges,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,30544.64,21381.248,AETNA [1000108],AETNA [100010801],,,77.2,,23580.46208,5734.05,24435.712,percent of total billed charges,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,23745.99,16622.193,AETNA [1000108],AETNA [100010801],,,77.2,,18331.90428,7771.48,38252.3528,percent of total billed charges,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,17630.01,12341.007,AETNA [1000108],AETNA [100010801],,,77.2,,13610.36772,5879.608335,18355.1312,percent of total billed charges,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,173078.09,121154.663,AETNA [1000108],AETNA [100010801],,,77.2,,133616.2855,7771.48,138462.472,percent of total billed charges,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,53859.21,37701.447,AETNA [1000108],AETNA [100010801],,,77.2,,41579.31012,7771.48,54390.6024,percent of total billed charges,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,inpatient,,,221306.62,154914.634,AETNA [1000108],AETNA [100010801],,,77.2,,170848.7106,7771.48,220737.7784,percent of total billed charges,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,354301.39,248010.973,AETNA [1000108],AETNA [100010801],,,77.2,,273520.6731,7771.48,283441.112,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC,216,MS-DRG,,,,,,,inpatient,,,299760.69,209832.483,AETNA [1000108],AETNA [100010801],,,77.2,,231415.2527,7771.48,239808.552,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,inpatient,,,204620.11,143234.077,AETNA [1000108],AETNA [100010801],,,77.2,,157966.7249,7771.48,163696.088,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC,219,MS-DRG,,,,,,,inpatient,,,208854.44,146198.108,AETNA [1000108],AETNA [100010801],,,77.2,,161235.6277,7771.48,167083.552,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,inpatient,,,154365.68,108055.976,AETNA [1000108],AETNA [100010801],,,77.2,,119170.305,7771.48,123492.544,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,181781.45,127247.015,AETNA [1000108],AETNA [100010801],,,77.2,,140335.2794,7771.48,145425.16,percent of total billed charges,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,228758.84,160131.188,AETNA [1000108],AETNA [100010801],,,77.2,,176601.8245,7771.48,183007.072,percent of total billed charges,
Other Cardiothoracic Procedures Without McC,229,MS-DRG,,,,,,,inpatient,,,95347.28,66743.096,AETNA [1000108],AETNA [100010801],,,77.2,,73608.10016,7771.48,76277.824,percent of total billed charges,
Coronary Bypass With Ptca With McC,231,MS-DRG,,,,,,,inpatient,,,220697.29,154488.103,AETNA [1000108],AETNA [100010801],,,77.2,,170378.3079,7771.48,176557.832,percent of total billed charges,
Coronary Bypass With Ptca Without McC,232,MS-DRG,,,,,,,inpatient,,,203083.55,142158.485,AETNA [1000108],AETNA [100010801],,,77.2,,156780.5006,7771.48,162466.84,percent of total billed charges,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,193515.4,135460.78,AETNA [1000108],AETNA [100010801],,,77.2,,149393.8888,7771.48,158379.3712,percent of total billed charges,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,165546.93,115882.851,AETNA [1000108],AETNA [100010801],,,77.2,,127802.23,7771.48,132437.544,percent of total billed charges,
Coronary Bypass Without Cardiac Catheterization With McC,235,MS-DRG,,,,,,,inpatient,,,145342.16,101739.512,AETNA [1000108],AETNA [100010801],,,77.2,,112204.1475,7771.48,119229.3232,percent of total billed charges,
Coronary Bypass Without Cardiac Catheterization Without McC,236,MS-DRG,,,,,,,inpatient,,,130227.12,91158.984,AETNA [1000108],AETNA [100010801],,,77.2,,100535.3366,7771.48,104181.696,percent of total billed charges,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,39344.02,27540.814,AETNA [1000108],AETNA [100010801],,,77.2,,30373.58344,7771.48,102059.636,percent of total billed charges,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,41409.42,28986.594,AETNA [1000108],AETNA [100010801],,,77.2,,31968.07224,7771.48,59008.768,percent of total billed charges,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC,241,MS-DRG,,,,,,,inpatient,,,19499.72,13649.804,AETNA [1000108],AETNA [100010801],,,77.2,,15053.78384,6503.15662,30594.5872,percent of total billed charges,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,76706.54,53694.578,AETNA [1000108],AETNA [100010801],,,77.2,,59217.44888,7771.48,68735.488,percent of total billed charges,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,63602.84,44521.988,AETNA [1000108],AETNA [100010801],,,77.2,,49101.39248,7771.48,50882.272,percent of total billed charges,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,60755.43,42528.801,AETNA [1000108],AETNA [100010801],,,77.2,,46903.19196,7771.48,48604.344,percent of total billed charges,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,109531.23,76671.861,AETNA [1000108],AETNA [100010801],,,77.2,,84558.10956,7771.48,99020.036,percent of total billed charges,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC,250,MS-DRG,,,,,,,inpatient,,,42609.28,29826.496,AETNA [1000108],AETNA [100010801],,,77.2,,32894.36416,7771.48,46864.5528,percent of total billed charges,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,52812.94,36969.058,AETNA [1000108],AETNA [100010801],,,77.2,,40771.58968,7771.48,42250.352,percent of total billed charges,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,100566.7,70396.69,AETNA [1000108],AETNA [100010801],,,77.2,,77637.4924,7771.48,80453.36,percent of total billed charges,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,72499.37,50749.559,AETNA [1000108],AETNA [100010801],,,77.2,,55969.51364,7771.48,57999.496,percent of total billed charges,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,68903.94,48232.758,AETNA [1000108],AETNA [100010801],,,77.2,,53193.84168,7771.48,55123.152,percent of total billed charges,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13134.86,9194.402,AETNA [1000108],AETNA [100010801],,,77.2,,10140.11192,4380.47581,34319.1104,percent of total billed charges,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,20863.13,14604.191,AETNA [1000108],AETNA [100010801],,,77.2,,16106.33636,6957.853855,18073.4616,percent of total billed charges,
Cardiac Pacemaker Device Replacement With McC,258,MS-DRG,,,,,,,inpatient,,,71596.9,50117.83,AETNA [1000108],AETNA [100010801],,,77.2,,55272.8068,7771.48,57277.52,percent of total billed charges,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,44827.64,31379.348,AETNA [1000108],AETNA [100010801],,,77.2,,34606.93808,7771.48,35862.112,percent of total billed charges,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,130030.35,91021.245,AETNA [1000108],AETNA [100010801],,,77.2,,100383.4302,7771.48,104024.28,percent of total billed charges,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,49670.67,34769.469,AETNA [1000108],AETNA [100010801],,,77.2,,38345.75724,7771.48,39736.536,percent of total billed charges,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC,262,MS-DRG,,,,,,,inpatient,,,58341.51,40839.057,AETNA [1000108],AETNA [100010801],,,77.2,,45039.64572,7771.48,46673.208,percent of total billed charges,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,49042.27,34329.589,AETNA [1000108],AETNA [100010801],,,77.2,,37860.63244,7771.48,70820.6536,percent of total billed charges,
Aicd Lead Procedures,265,MS-DRG,,,,,,,inpatient,,,64208.05,44945.635,AETNA [1000108],AETNA [100010801],,,77.2,,49568.6146,7771.48,72279.6616,percent of total billed charges,
Endovascular Cardiac Valve Replacement And Supplement Procedures With McC,266,MS-DRG,,,,,,,inpatient,,,134751.65,94326.155,AETNA [1000108],AETNA [100010801],,,77.2,,104028.2738,7771.48,121389.4656,percent of total billed charges,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC,267,MS-DRG,,,,,,,inpatient,,,133372.27,93360.589,AETNA [1000108],AETNA [100010801],,,77.2,,102963.3924,7771.48,106697.816,percent of total billed charges,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,241728.99,169210.293,AETNA [1000108],AETNA [100010801],,,77.2,,186614.7803,7771.48,193383.192,percent of total billed charges,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,132639.05,92847.335,AETNA [1000108],AETNA [100010801],,,77.2,,102397.3466,7771.48,106111.24,percent of total billed charges,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,135782.35,95047.645,AETNA [1000108],AETNA [100010801],,,77.2,,104823.9742,7771.48,108625.88,percent of total billed charges,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,140000.81,98000.567,AETNA [1000108],AETNA [100010801],,,77.2,,108080.6253,7771.48,112000.648,percent of total billed charges,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,151532.98,106073.086,AETNA [1000108],AETNA [100010801],,,77.2,,116983.4606,7771.48,121226.384,percent of total billed charges,
Percutaneous And Other Intracardiac Procedures With McC,273,MS-DRG,,,,,,,inpatient,,,102782.81,71947.967,AETNA [1000108],AETNA [100010801],,,77.2,,79348.32932,7771.48,82226.248,percent of total billed charges,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,82201.95,57541.365,AETNA [1000108],AETNA [100010801],,,77.2,,63459.9054,7771.48,65761.56,percent of total billed charges,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,183325.52,128327.864,AETNA [1000108],AETNA [100010801],,,77.2,,141527.3014,7771.48,146660.416,percent of total billed charges,
Cardiac Defibrillator Implant With McC,276,MS-DRG,,,,,,,inpatient,,,196887.28,137821.096,AETNA [1000108],AETNA [100010801],,,77.2,,151996.9802,7771.48,157509.824,percent of total billed charges,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,177791.04,124453.728,AETNA [1000108],AETNA [100010801],,,77.2,,137254.6829,7771.48,142232.832,percent of total billed charges,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,157626.97,110338.879,AETNA [1000108],AETNA [100010801],,,77.2,,121688.0208,7771.48,126101.576,percent of total billed charges,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,93744.91,65621.437,AETNA [1000108],AETNA [100010801],,,77.2,,72371.07052,7771.48,74995.928,percent of total billed charges,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31041.23,21728.861,AETNA [1000108],AETNA [100010801],,,77.2,,23963.82956,7771.48,33263.356,percent of total billed charges,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,26543.44,18580.408,AETNA [1000108],AETNA [100010801],,,77.2,,20491.53568,6744.11,21234.752,percent of total billed charges,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,23815.3,16670.71,AETNA [1000108],AETNA [100010801],,,77.2,,18385.4116,5249.28,19052.24,percent of total billed charges,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,19212.47,13448.729,AETNA [1000108],AETNA [100010801],,,77.2,,14832.02684,6407.358745,39624.2256,percent of total billed charges,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,10954.07,7667.849,AETNA [1000108],AETNA [100010801],,,77.2,,8456.54204,3653.182345,15013.5976,percent of total billed charges,
Acute Myocardial Infarction- Expired Without Cc/McC,285,MS-DRG,,,,,,,inpatient,,,7163.26,5014.282,AETNA [1000108],AETNA [100010801],,,77.2,,5530.03672,2388.94721,11374.1832,percent of total billed charges,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,38892.53,27224.771,AETNA [1000108],AETNA [100010801],,,77.2,,30025.03316,7771.48,44850.3112,percent of total billed charges,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,30727.74,21509.418,AETNA [1000108],AETNA [100010801],,,77.2,,23721.81528,7771.48,24582.192,percent of total billed charges,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,28457.96,19920.572,AETNA [1000108],AETNA [100010801],,,77.2,,21969.54512,7771.48,55347.0632,percent of total billed charges,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,19767.12,13836.984,AETNA [1000108],AETNA [100010801],,,77.2,,15260.21664,6592.33452,31948.2224,percent of total billed charges,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,20727.01,14508.907,AETNA [1000108],AETNA [100010801],,,77.2,,16001.25172,6912.457835,26442.4936,percent of total billed charges,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,15225.15,10657.605,AETNA [1000108],AETNA [100010801],,,77.2,,11753.8158,5077.587525,17453.3832,percent of total billed charges,
Heart Failure And Shock Without Cc/McC,293,MS-DRG,,,,,,,inpatient,,,10124.22,7086.954,AETNA [1000108],AETNA [100010801],,,77.2,,7815.89784,3376.42737,11124.936,percent of total billed charges,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,25950.27,18165.189,AETNA [1000108],AETNA [100010801],,,77.2,,20033.60844,7771.48,33198.5112,percent of total billed charges,
Cardiac Arrest- Unexplained With Cc,297,MS-DRG,,,,,,,inpatient,,,10642.36,7449.652,AETNA [1000108],AETNA [100010801],,,77.2,,8215.90192,3549.22706,14273.9616,percent of total billed charges,
Cardiac Arrest- Unexplained Without Cc/McC,298,MS-DRG,,,,,,,inpatient,,,12953.57,9067.499,AETNA [1000108],AETNA [100010801],,,77.2,,10000.15604,4151.065639,10362.856,percent of total billed charges,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,22073.95,15451.765,AETNA [1000108],AETNA [100010801],,,77.2,,17041.0894,7361.662325,32781.0728,percent of total billed charges,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,21942.88,15360.016,AETNA [1000108],AETNA [100010801],,,77.2,,16939.90336,7317.95048,21692.612,percent of total billed charges,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,24649.73,17254.811,AETNA [1000108],AETNA [100010801],,,77.2,,19029.59156,5372.28,19719.784,percent of total billed charges,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,9953.04,6967.128,AETNA [1000108],AETNA [100010801],,,77.2,,7683.74688,3319.33884,23571.0848,percent of total billed charges,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16791.27,11753.889,AETNA [1000108],AETNA [100010801],,,77.2,,12962.86044,4894.02,13625.5136,percent of total billed charges,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,37676.15,26373.305,AETNA [1000108],AETNA [100010801],,,77.2,,29085.9878,7771.48,30140.92,percent of total billed charges,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,16488.7,11542.09,AETNA [1000108],AETNA [100010801],,,77.2,,12729.2764,5343.34,15212.1848,percent of total billed charges,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,22172.6,15520.82,AETNA [1000108],AETNA [100010801],,,77.2,,17117.2472,7394.5621,30343.3136,percent of total billed charges,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,15582.95,10908.065,AETNA [1000108],AETNA [100010801],,,77.2,,12030.0374,5196.913825,18770.5432,percent of total billed charges,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,19410.63,13587.441,AETNA [1000108],AETNA [100010801],,,77.2,,14985.00636,6473.445105,24438.384,percent of total billed charges,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,14290.45,10003.315,AETNA [1000108],AETNA [100010801],,,77.2,,11032.2274,4765.865075,14981.1752,percent of total billed charges,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,11407.4,7985.18,AETNA [1000108],AETNA [100010801],,,77.2,,8806.5128,3804.3679,11337.708,percent of total billed charges,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,11897.35,8328.145,AETNA [1000108],AETNA [100010801],,,77.2,,9184.7542,3967.766225,14154.404,percent of total billed charges,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,16541.17,11578.819,AETNA [1000108],AETNA [100010801],,,77.2,,12769.78324,5516.480195,17656.0232,percent of total billed charges,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,15084.64,10559.248,AETNA [1000108],AETNA [100010801],,,77.2,,11645.34208,5030.72744,14454.3112,percent of total billed charges,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,31164.15,21814.905,AETNA [1000108],AETNA [100010801],,,77.2,,24058.7238,7771.48,43636.4976,percent of total billed charges,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,18201.8,12741.26,AETNA [1000108],AETNA [100010801],,,77.2,,14051.7896,6070.3003,19500.0472,percent of total billed charges,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,10045.09,7031.563,AETNA [1000108],AETNA [100010801],,,77.2,,7754.80948,3350.037515,13832.2064,percent of total billed charges,
Other Endovascular Cardiac Valve Procedures With McC,319,MS-DRG,,,,,,,inpatient,,,92577.92,64804.544,AETNA [1000108],AETNA [100010801],,,77.2,,71470.15424,7771.48,89009.62,percent of total billed charges,
Other Endovascular Cardiac Valve Procedures Without McC,320,MS-DRG,,,,,,,inpatient,,,39673.91,27771.737,AETNA [1000108],AETNA [100010801],,,77.2,,30628.25852,7771.48,46903.0544,percent of total billed charges,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,92249.33,64574.531,AETNA [1000108],AETNA [100010801],,,77.2,,71216.48276,7771.48,73799.464,percent of total billed charges,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,75877.65,53114.355,AETNA [1000108],AETNA [100010801],,,77.2,,58577.5458,7771.48,60702.12,percent of total billed charges,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,116736.51,81715.557,AETNA [1000108],AETNA [100010801],,,77.2,,90120.58572,7771.48,93389.208,percent of total billed charges,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,126333.04,88433.128,AETNA [1000108],AETNA [100010801],,,77.2,,97529.10688,7771.48,101066.432,percent of total billed charges,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,inpatient,,,98701.5,69091.05,AETNA [1000108],AETNA [100010801],,,77.2,,76197.558,7771.48,78961.2,percent of total billed charges,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,64991.97,45494.379,AETNA [1000108],AETNA [100010801],,,77.2,,50173.80084,7771.48,102914.7768,percent of total billed charges,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,59110.49,41377.343,AETNA [1000108],AETNA [100010801],,,77.2,,45633.29828,7771.48,49203.0184,percent of total billed charges,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,49561.22,34692.854,AETNA [1000108],AETNA [100010801],,,77.2,,38261.26184,7771.48,39648.976,percent of total billed charges,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,78913.19,55239.233,AETNA [1000108],AETNA [100010801],,,77.2,,60920.98268,7771.48,93046.2088,percent of total billed charges,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,69586.46,48710.522,AETNA [1000108],AETNA [100010801],,,77.2,,53720.74712,7771.48,55669.168,percent of total billed charges,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,57546.85,40282.795,AETNA [1000108],AETNA [100010801],,,77.2,,44426.1682,7771.48,46037.48,percent of total billed charges,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,97325,68127.5,AETNA [1000108],AETNA [100010801],,,77.2,,75134.9,7771.48,77860,percent of total billed charges,
Rectal Resection Without Cc/McC,334,MS-DRG,,,,,,,inpatient,,,106215.45,74350.815,AETNA [1000108],AETNA [100010801],,,77.2,,81998.3274,7771.48,84972.36,percent of total billed charges,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,73034.84,51124.388,AETNA [1000108],AETNA [100010801],,,77.2,,56382.89648,7771.48,73434.7096,percent of total billed charges,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,43630.89,30541.623,AETNA [1000108],AETNA [100010801],,,77.2,,33683.04708,7771.48,42805.6736,percent of total billed charges,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,37370.19,26159.133,AETNA [1000108],AETNA [100010801],,,77.2,,28849.78668,7771.48,31105.24,percent of total billed charges,
Minor Small And Large Bowel Procedures With McC,344,MS-DRG,,,,,,,inpatient,,,23852.76,16696.932,AETNA [1000108],AETNA [100010801],,,77.2,,18414.33072,7771.48,54599.3216,percent of total billed charges,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,15908.61,11136.027,AETNA [1000108],AETNA [100010801],,,77.2,,12281.44692,5305.521435,30177.1488,percent of total billed charges,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,21216.99,14851.893,AETNA [1000108],AETNA [100010801],,,77.2,,16379.51628,7075.866165,25232.7328,percent of total billed charges,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,44922.74,31445.918,AETNA [1000108],AETNA [100010801],,,77.2,,34680.35528,7771.48,47956.7824,percent of total billed charges,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,23475.59,16432.913,AETNA [1000108],AETNA [100010801],,,77.2,,18123.15548,7771.48,25508.3232,percent of total billed charges,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,34354.1,24047.87,AETNA [1000108],AETNA [100010801],,,77.2,,26521.3652,7771.48,30491.2408,percent of total billed charges,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,42230.08,29561.056,AETNA [1000108],AETNA [100010801],,,77.2,,32601.62176,7771.48,33784.064,percent of total billed charges,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,312395.2,218676.64,AETNA [1000108],AETNA [100010801],,,77.2,,241169.0944,7771.48,249916.16,percent of total billed charges,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,44235.04,30964.528,AETNA [1000108],AETNA [100010801],,,77.2,,34149.45088,7771.48,35388.032,percent of total billed charges,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,51507.45,36055.215,AETNA [1000108],AETNA [100010801],,,77.2,,39763.7514,7771.48,41205.96,percent of total billed charges,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,70735.47,49514.829,AETNA [1000108],AETNA [100010801],,,77.2,,54607.78284,7771.48,86434.0656,percent of total billed charges,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,77577.93,54304.551,AETNA [1000108],AETNA [100010801],,,77.2,,59890.16196,7771.48,62062.344,percent of total billed charges,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,27080.24,18956.168,AETNA [1000108],AETNA [100010801],,,77.2,,20905.94528,7771.48,27457.72,percent of total billed charges,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,23431.55,16402.085,AETNA [1000108],AETNA [100010801],,,77.2,,18089.1566,7771.48,33838.8536,percent of total billed charges,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,31489.94,22042.958,AETNA [1000108],AETNA [100010801],,,77.2,,24310.23368,7771.48,25191.952,percent of total billed charges,
Major Esophageal Disorders Without Cc/McC,370,MS-DRG,,,,,,,inpatient,,,29793.71,20855.597,AETNA [1000108],AETNA [100010801],,,77.2,,23000.74412,5409.18,23834.968,percent of total billed charges,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,37215.27,26050.689,AETNA [1000108],AETNA [100010801],,,77.2,,28730.18844,7771.48,35427.5512,percent of total billed charges,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,24764.87,17335.409,AETNA [1000108],AETNA [100010801],,,77.2,,19118.47964,7435.09,20857.7352,percent of total billed charges,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,19807.89,13865.523,AETNA [1000108],AETNA [100010801],,,77.2,,15291.69108,5379.51,15846.312,percent of total billed charges,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,38795.7,27156.99,AETNA [1000108],AETNA [100010801],,,77.2,,29950.2804,7771.48,42787.436,percent of total billed charges,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,40108.1,28075.67,AETNA [1000108],AETNA [100010801],,,77.2,,30963.4532,7771.48,32086.48,percent of total billed charges,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,8031.54,5622.078,AETNA [1000108],AETNA [100010801],,,77.2,,6200.34888,2678.51859,17891.0856,percent of total billed charges,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,38252.31,26776.617,AETNA [1000108],AETNA [100010801],,,77.2,,29530.78332,7771.48,36841.9784,percent of total billed charges,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,30659.48,21461.636,AETNA [1000108],AETNA [100010801],,,77.2,,23669.11856,7186.19,24527.584,percent of total billed charges,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,17080.5,11956.35,AETNA [1000108],AETNA [100010801],,,77.2,,13186.146,4609.67,13664.4,percent of total billed charges,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33361.1,23352.77,AETNA [1000108],AETNA [100010801],,,77.2,,25754.7692,7771.48,38994.0152,percent of total billed charges,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,34876.59,24413.613,AETNA [1000108],AETNA [100010801],,,77.2,,26924.72748,7667.34,27901.272,percent of total billed charges,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,23295.58,16306.906,AETNA [1000108],AETNA [100010801],,,77.2,,17984.18776,6456.86,18636.464,percent of total billed charges,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,19010.83,13307.581,AETNA [1000108],AETNA [100010801],,,77.2,,14676.36076,6340.111805,32922.9208,percent of total billed charges,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,17687.57,12381.299,AETNA [1000108],AETNA [100010801],,,77.2,,13654.80404,5898.804595,20109.9936,percent of total billed charges,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12268.03,8587.621,AETNA [1000108],AETNA [100010801],,,77.2,,9470.91916,4091.388005,13582.9592,percent of total billed charges,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,35037.99,24526.593,AETNA [1000108],AETNA [100010801],,,77.2,,27049.32828,7771.48,29788.08,percent of total billed charges,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,19193.48,13435.436,AETNA [1000108],AETNA [100010801],,,77.2,,14817.36656,5946.04,16245.6488,percent of total billed charges,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12403.72,8682.604,AETNA [1000108],AETNA [100010801],,,77.2,,9575.67184,4136.64062,11086.4344,percent of total billed charges,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,23697.98,16588.586,AETNA [1000108],AETNA [100010801],,,77.2,,18294.84056,7771.48,26037.2136,percent of total billed charges,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16680.62,11676.434,AETNA [1000108],AETNA [100010801],,,77.2,,12877.43864,5530.73,15811.9992,percent of total billed charges,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,35226.46,24658.522,AETNA [1000108],AETNA [100010801],,,77.2,,27194.82712,7771.48,33555.1576,percent of total billed charges,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,21027.93,14719.551,AETNA [1000108],AETNA [100010801],,,77.2,,16233.56196,6791.14,19074.5032,percent of total billed charges,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,19292.51,13504.757,AETNA [1000108],AETNA [100010801],,,77.2,,14893.81772,4700.83,15434.008,percent of total billed charges,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,31379.86,21965.902,AETNA [1000108],AETNA [100010801],,,77.2,,24225.25192,7771.48,50206.0864,percent of total billed charges,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,37379.45,26165.615,AETNA [1000108],AETNA [100010801],,,77.2,,28856.9354,7771.48,30665.5112,percent of total billed charges,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,31865.55,22305.885,AETNA [1000108],AETNA [100010801],,,77.2,,24600.2046,7771.48,25492.44,percent of total billed charges,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,43167.44,30217.208,AETNA [1000108],AETNA [100010801],,,77.2,,33325.26368,7771.48,56905.3648,percent of total billed charges,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,37981.98,26587.386,AETNA [1000108],AETNA [100010801],,,77.2,,29322.08856,7771.48,43275.7984,percent of total billed charges,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC,408,MS-DRG,,,,,,,inpatient,,,66496.81,46547.767,AETNA [1000108],AETNA [100010801],,,77.2,,51335.53732,7771.48,70946.2904,percent of total billed charges,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,54723.42,38306.394,AETNA [1000108],AETNA [100010801],,,77.2,,42246.48024,7771.48,43778.736,percent of total billed charges,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC,410,MS-DRG,,,,,,,inpatient,,,49332.9,34533.03,AETNA [1000108],AETNA [100010801],,,77.2,,38084.9988,7771.48,39466.32,percent of total billed charges,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,inpatient,,,94854.82,66398.374,AETNA [1000108],AETNA [100010801],,,77.2,,73227.92104,7771.48,75883.856,percent of total billed charges,
Cholecystectomy Except By Laparoscope Without C.D.E. With McC,414,MS-DRG,,,,,,,inpatient,,,158479.92,110935.944,AETNA [1000108],AETNA [100010801],,,77.2,,122346.4982,7771.48,126783.936,percent of total billed charges,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/McC,416,MS-DRG,,,,,,,inpatient,,,36054.28,25237.996,AETNA [1000108],AETNA [100010801],,,77.2,,27833.90416,7771.48,28843.424,percent of total billed charges,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,57775.9,40443.13,AETNA [1000108],AETNA [100010801],,,77.2,,44602.9948,7771.48,48157.396,percent of total billed charges,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,45650.74,31955.518,AETNA [1000108],AETNA [100010801],,,77.2,,35242.37128,7771.48,36520.592,percent of total billed charges,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,40583.9,28408.73,AETNA [1000108],AETNA [100010801],,,77.2,,31330.7708,7771.48,32467.12,percent of total billed charges,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,43141.15,30198.805,AETNA [1000108],AETNA [100010801],,,77.2,,33304.9678,7771.48,71515.7088,percent of total billed charges,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,126455.95,88519.165,AETNA [1000108],AETNA [100010801],,,77.2,,97623.9934,7771.48,101164.76,percent of total billed charges,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,inpatient,,,66431.87,46502.309,AETNA [1000108],AETNA [100010801],,,77.2,,51285.40364,7771.48,53145.496,percent of total billed charges,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,37750.2,26425.14,AETNA [1000108],AETNA [100010801],,,77.2,,29143.1544,7771.48,39699.2024,percent of total billed charges,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,22206.74,15544.718,AETNA [1000108],AETNA [100010801],,,77.2,,17143.60328,7405.94779,21676.4008,percent of total billed charges,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,9888.24,6921.768,AETNA [1000108],AETNA [100010801],,,77.2,,7633.72128,3297.72804,14111.8496,percent of total billed charges,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41222.48,28855.736,AETNA [1000108],AETNA [100010801],,,77.2,,31823.75456,7771.48,36971.668,percent of total billed charges,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,21857.06,15299.942,AETNA [1000108],AETNA [100010801],,,77.2,,16873.65032,7289.32951,22849.6864,percent of total billed charges,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,34142.65,23899.855,AETNA [1000108],AETNA [100010801],,,77.2,,26358.1258,7771.48,33715.2432,percent of total billed charges,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,18774.77,13142.339,AETNA [1000108],AETNA [100010801],,,77.2,,14494.12244,6109.56,17431.0928,percent of total billed charges,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,12926.06,9048.242,AETNA [1000108],AETNA [100010801],,,77.2,,9978.91832,4310.84101,12464.3864,percent of total billed charges,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,33617.1,23531.97,AETNA [1000108],AETNA [100010801],,,77.2,,25952.4012,7771.48,38305.0392,percent of total billed charges,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,18826.25,13178.375,AETNA [1000108],AETNA [100010801],,,77.2,,14533.865,6278.554375,19579.0768,percent of total billed charges,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,9263.58,6484.506,AETNA [1000108],AETNA [100010801],,,77.2,,7151.48376,3089.40393,14237.4864,percent of total billed charges,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,36248.92,25374.244,AETNA [1000108],AETNA [100010801],,,77.2,,27984.16624,7771.48,34134.708,percent of total billed charges,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,33226.4,23258.48,AETNA [1000108],AETNA [100010801],,,77.2,,25650.7808,7771.48,26581.12,percent of total billed charges,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,28308.58,19816.006,AETNA [1000108],AETNA [100010801],,,77.2,,21854.22376,5905.53,22646.864,percent of total billed charges,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,114168.82,79918.174,AETNA [1000108],AETNA [100010801],,,77.2,,88138.32904,7771.48,91335.056,percent of total billed charges,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,93512.08,65458.456,AETNA [1000108],AETNA [100010801],,,77.2,,72191.32576,7771.48,74809.664,percent of total billed charges,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With McC,456,MS-DRG,,,,,,,inpatient,,,202351.8,141646.26,AETNA [1000108],AETNA [100010801],,,77.2,,156215.5896,7771.48,171607.7104,percent of total billed charges,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,152088.75,106462.125,AETNA [1000108],AETNA [100010801],,,77.2,,117412.515,7771.48,121671,percent of total billed charges,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,114206.41,79944.487,AETNA [1000108],AETNA [100010801],,,77.2,,88167.34852,7771.48,91365.128,percent of total billed charges,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,70294.35,49206.045,AETNA [1000108],AETNA [100010801],,,77.2,,54267.2382,7771.48,109439.7848,percent of total billed charges,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,25826.71,18078.697,AETNA [1000108],AETNA [100010801],,,77.2,,19938.22012,7771.48,59750.4304,percent of total billed charges,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,10589.98,7412.986,AETNA [1000108],AETNA [100010801],,,77.2,,8175.46456,3531.75833,35176.2776,percent of total billed charges,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,134518.68,94163.076,AETNA [1000108],AETNA [100010801],,,77.2,,103848.421,7771.48,107614.944,percent of total billed charges,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,95919.47,67143.629,AETNA [1000108],AETNA [100010801],,,77.2,,74049.83084,7771.48,76735.576,percent of total billed charges,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,68797.87,48158.509,AETNA [1000108],AETNA [100010801],,,77.2,,53111.95564,7771.48,55038.296,percent of total billed charges,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,54280.26,37996.182,AETNA [1000108],AETNA [100010801],,,77.2,,41904.36072,7771.48,66232.884,percent of total billed charges,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,53419.21,37393.447,AETNA [1000108],AETNA [100010801],,,77.2,,41239.63012,7771.48,42735.368,percent of total billed charges,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68987.67,48291.369,AETNA [1000108],AETNA [100010801],,,77.2,,53258.48124,7771.48,98422.248,percent of total billed charges,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,77778.52,54444.964,AETNA [1000108],AETNA [100010801],,,77.2,,60045.01744,7771.48,62222.816,percent of total billed charges,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,54869.65,38408.755,AETNA [1000108],AETNA [100010801],,,77.2,,42359.3698,7771.48,47968.9408,percent of total billed charges,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,71787.88,50251.516,AETNA [1000108],AETNA [100010801],,,77.2,,55420.24336,7771.48,90871.8816,percent of total billed charges,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,33747.79,23623.453,AETNA [1000108],AETNA [100010801],,,77.2,,26053.29388,7771.48,43711.4744,percent of total billed charges,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,89768.8,62838.16,AETNA [1000108],AETNA [100010801],,,77.2,,69301.5136,7771.48,71815.04,percent of total billed charges,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,65676.03,45973.221,AETNA [1000108],AETNA [100010801],,,77.2,,50701.89516,7771.48,52540.824,percent of total billed charges,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,26493.14,18545.198,AETNA [1000108],AETNA [100010801],,,77.2,,20452.70408,7771.48,35982.7848,percent of total billed charges,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,50028.86,35020.202,AETNA [1000108],AETNA [100010801],,,77.2,,38622.27992,7771.48,59596.424,percent of total billed charges,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,54052.44,37836.708,AETNA [1000108],AETNA [100010801],,,77.2,,41728.48368,7771.48,43241.952,percent of total billed charges,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,42724.18,29906.926,AETNA [1000108],AETNA [100010801],,,77.2,,32983.06696,7771.48,34179.344,percent of total billed charges,
Knee Procedures With Principal Diagnosis Of Infection With McC,485,MS-DRG,,,,,,,inpatient,,,78688.59,55082.013,AETNA [1000108],AETNA [100010801],,,77.2,,60747.59148,7771.48,65323.0304,percent of total billed charges,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,38633.42,27043.394,AETNA [1000108],AETNA [100010801],,,77.2,,29825.00024,7771.48,42973.8648,percent of total billed charges,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,68635.57,48044.899,AETNA [1000108],AETNA [100010801],,,77.2,,52986.66004,7771.48,54908.456,percent of total billed charges,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,35436.81,24805.767,AETNA [1000108],AETNA [100010801],,,77.2,,27357.21732,7771.48,28349.448,percent of total billed charges,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,77413.36,54189.352,AETNA [1000108],AETNA [100010801],,,77.2,,59763.11392,7771.48,71957.464,percent of total billed charges,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,79988.8,55992.16,AETNA [1000108],AETNA [100010801],,,77.2,,61751.3536,7771.48,63991.04,percent of total billed charges,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,52007.74,36405.418,AETNA [1000108],AETNA [100010801],,,77.2,,40149.97528,7771.48,41606.192,percent of total billed charges,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC,495,MS-DRG,,,,,,,inpatient,,,55215.82,38651.074,AETNA [1000108],AETNA [100010801],,,77.2,,42626.61304,7771.48,71335.3592,percent of total billed charges,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC,499,MS-DRG,,,,,,,inpatient,,,24343.66,17040.562,AETNA [1000108],AETNA [100010801],,,77.2,,18793.30552,7771.48,23522.4512,percent of total billed charges,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,43692.12,30584.484,AETNA [1000108],AETNA [100010801],,,77.2,,33730.31664,7771.48,64206.484,percent of total billed charges,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,30673.94,21471.758,AETNA [1000108],AETNA [100010801],,,77.2,,23680.28168,7771.48,36169.2136,percent of total billed charges,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,41306.96,28914.872,AETNA [1000108],AETNA [100010801],,,77.2,,31888.97312,7771.48,53628.676,percent of total billed charges,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,37180.29,26026.203,AETNA [1000108],AETNA [100010801],,,77.2,,28703.18388,7771.48,35575.4784,percent of total billed charges,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,63266.34,44286.438,AETNA [1000108],AETNA [100010801],,,77.2,,48841.61448,7771.48,50613.072,percent of total billed charges,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,57782.59,40447.813,AETNA [1000108],AETNA [100010801],,,77.2,,44608.15948,7771.48,57914.512,percent of total billed charges,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,39749.27,27824.489,AETNA [1000108],AETNA [100010801],,,77.2,,30686.43644,7771.48,39745.8096,percent of total billed charges,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,26213.06,18349.142,AETNA [1000108],AETNA [100010801],,,77.2,,20236.48232,7771.48,30507.452,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,64680.35,45276.245,AETNA [1000108],AETNA [100010801],,,77.2,,49933.2302,7771.48,62660.3408,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,33187.16,23231.012,AETNA [1000108],AETNA [100010801],,,77.2,,25620.48752,7771.48,40763.0624,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,28664.41,20065.087,AETNA [1000108],AETNA [100010801],,,77.2,,22128.92452,7771.48,30246.0464,percent of total billed charges,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,52006.98,36404.886,AETNA [1000108],AETNA [100010801],,,77.2,,40149.38856,7771.48,72622.1232,percent of total billed charges,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,60945.78,42662.046,AETNA [1000108],AETNA [100010801],,,77.2,,47050.14216,7771.48,48756.624,percent of total billed charges,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,27733.63,19413.541,AETNA [1000108],AETNA [100010801],,,77.2,,21410.36236,7771.48,29040.3384,percent of total billed charges,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,64155.47,44908.829,AETNA [1000108],AETNA [100010801],,,77.2,,49528.02284,7771.48,59061.4544,percent of total billed charges,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59467.45,41627.215,AETNA [1000108],AETNA [100010801],,,77.2,,45908.8714,7771.48,47573.96,percent of total billed charges,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,24348.24,17043.768,AETNA [1000108],AETNA [100010801],,,77.2,,18796.84128,7771.48,26949.0936,percent of total billed charges,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,14748.61,10324.027,AETNA [1000108],AETNA [100010801],,,77.2,,11385.92692,4918.661435,16432.0776,percent of total billed charges,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,34525.72,24168.004,AETNA [1000108],AETNA [100010801],,,77.2,,26653.85584,7771.48,40987.9928,percent of total billed charges,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,27528.18,19269.726,AETNA [1000108],AETNA [100010801],,,77.2,,21251.75496,7771.48,26229.7216,percent of total billed charges,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,28046.03,19632.221,AETNA [1000108],AETNA [100010801],,,77.2,,21651.53516,7771.48,37790.3336,percent of total billed charges,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,29133.49,20393.443,AETNA [1000108],AETNA [100010801],,,77.2,,22491.05428,7548.68,23306.792,percent of total billed charges,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,17251.52,12076.064,AETNA [1000108],AETNA [100010801],,,77.2,,13318.17344,5616.11,15313.5048,percent of total billed charges,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,10607.77,7425.439,AETNA [1000108],AETNA [100010801],,,77.2,,8189.19844,3537.691295,51201.0488,percent of total billed charges,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,22929.4,16050.58,AETNA [1000108],AETNA [100010801],,,77.2,,17701.4968,7646.9549,23459.6328,percent of total billed charges,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,15898.64,11129.048,AETNA [1000108],AETNA [100010801],,,77.2,,12273.75008,5302.19644,15120.9968,percent of total billed charges,
Septic Arthritis Without Cc/McC,550,MS-DRG,,,,,,,inpatient,,,13751.03,9625.721,AETNA [1000108],AETNA [100010801],,,77.2,,10615.79516,4585.968505,17469.5944,percent of total billed charges,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,34050.51,23835.357,AETNA [1000108],AETNA [100010801],,,77.2,,26286.99372,7771.48,34576.4632,percent of total billed charges,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,21070.26,14749.182,AETNA [1000108],AETNA [100010801],,,77.2,,16266.24072,6815.74,19530.4432,percent of total billed charges,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,37105.01,25973.507,AETNA [1000108],AETNA [100010801],,,77.2,,28645.06772,7771.48,29684.008,percent of total billed charges,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,33214.93,23250.451,AETNA [1000108],AETNA [100010801],,,77.2,,25641.92596,5718.85,26571.944,percent of total billed charges,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC,555,MS-DRG,,,,,,,inpatient,,,16910.44,11837.308,AETNA [1000108],AETNA [100010801],,,77.2,,13054.85968,5639.63174,27285.476,percent of total billed charges,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,38978.42,27284.894,AETNA [1000108],AETNA [100010801],,,77.2,,30091.34024,5833.89,31182.736,percent of total billed charges,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,25775.81,18043.067,AETNA [1000108],AETNA [100010801],,,77.2,,19898.92532,7771.48,31403.1208,percent of total billed charges,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,17322.32,12125.624,AETNA [1000108],AETNA [100010801],,,77.2,,13372.83104,5776.99372,17504.0432,percent of total billed charges,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,46066.43,32246.501,AETNA [1000108],AETNA [100010801],,,77.2,,35563.28396,7771.48,37612.0104,percent of total billed charges,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,43659.99,30561.993,AETNA [1000108],AETNA [100010801],,,77.2,,33705.51228,7771.48,34927.992,percent of total billed charges,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,35419.71,24793.797,AETNA [1000108],AETNA [100010801],,,77.2,,27344.01612,5723.92,28335.768,percent of total billed charges,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,23360.4,16352.28,AETNA [1000108],AETNA [100010801],,,77.2,,18034.2288,7771.48,29660.4168,percent of total billed charges,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,23376.03,16363.221,AETNA [1000108],AETNA [100010801],,,77.2,,18046.29516,6300.58,18700.824,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,24152.97,16907.079,AETNA [1000108],AETNA [100010801],,,77.2,,18646.09284,7771.48,31798.2688,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,26103.05,18272.135,AETNA [1000108],AETNA [100010801],,,77.2,,20151.5546,7280.97,20882.44,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,12203.73,8542.611,AETNA [1000108],AETNA [100010801],,,77.2,,9421.27956,4069.943955,15157.472,percent of total billed charges,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,58121.61,40685.127,AETNA [1000108],AETNA [100010801],,,77.2,,44869.88292,7771.48,61002.7456,percent of total billed charges,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,22908.56,16035.992,AETNA [1000108],AETNA [100010801],,,77.2,,17685.40832,7640.00476,33938.1472,percent of total billed charges,
Skin Debridement Without Cc/McC,572,MS-DRG,,,,,,,inpatient,,,34042.21,23829.547,AETNA [1000108],AETNA [100010801],,,77.2,,26280.58612,7771.48,27233.768,percent of total billed charges,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,40320.12,28224.084,AETNA [1000108],AETNA [100010801],,,77.2,,31127.13264,7771.48,124781.6592,percent of total billed charges,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,31675.49,22172.843,AETNA [1000108],AETNA [100010801],,,77.2,,24453.47828,7771.48,70208.6808,percent of total billed charges,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC,575,MS-DRG,,,,,,,inpatient,,,33248.67,23274.069,AETNA [1000108],AETNA [100010801],,,77.2,,25667.97324,7771.48,40457.076,percent of total billed charges,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,inpatient,,,22694.73,15886.311,AETNA [1000108],AETNA [100010801],,,77.2,,17520.33156,7568.692455,53954.9264,percent of total billed charges,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,47774,33441.8,AETNA [1000108],AETNA [100010801],,,77.2,,36881.528,7771.48,66042.4024,percent of total billed charges,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,21385.31,14969.717,AETNA [1000108],AETNA [100010801],,,77.2,,16509.45932,7132.000885,35926.0456,percent of total billed charges,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,107178.51,75024.957,AETNA [1000108],AETNA [100010801],,,77.2,,82741.80972,7771.48,85742.808,percent of total billed charges,
Breast Biopsy- Local Excision And Other Breast Procedures Without Cc/McC,585,MS-DRG,,,,,,,inpatient,,,37278.64,26095.048,AETNA [1000108],AETNA [100010801],,,77.2,,28779.11008,7771.48,40224.04,percent of total billed charges,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,53897.07,37727.949,AETNA [1000108],AETNA [100010801],,,77.2,,41608.53804,7771.48,43117.656,percent of total billed charges,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,22540.18,15778.126,AETNA [1000108],AETNA [100010801],,,77.2,,17401.01896,5923.61,18032.144,percent of total billed charges,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,26958.01,18870.607,AETNA [1000108],AETNA [100010801],,,77.2,,20811.58372,7157.25,21905.384,percent of total billed charges,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,36927.76,25849.432,AETNA [1000108],AETNA [100010801],,,77.2,,28508.23072,7771.48,35593.716,percent of total billed charges,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,9105.56,6373.892,AETNA [1000108],AETNA [100010801],,,77.2,,7029.49232,3036.70426,21862.8296,percent of total billed charges,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,5148.62,3604.034,AETNA [1000108],AETNA [100010801],,,77.2,,3974.73464,1717.06477,12148.268,percent of total billed charges,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,21201.17,14840.819,AETNA [1000108],AETNA [100010801],,,77.2,,16367.30324,7070.590195,29775.9216,percent of total billed charges,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,14711.96,10298.372,AETNA [1000108],AETNA [100010801],,,77.2,,11357.63312,4906.43866,17850.5576,percent of total billed charges,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,29329.16,20530.412,AETNA [1000108],AETNA [100010801],,,77.2,,22642.11152,7771.48,30106.2248,percent of total billed charges,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21984.9,15389.43,AETNA [1000108],AETNA [100010801],,,77.2,,16972.3428,6578.42,18717.8568,percent of total billed charges,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,26207.89,18345.523,AETNA [1000108],AETNA [100010801],,,77.2,,20232.49108,7771.48,32627.0664,percent of total billed charges,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,18364.58,12855.206,AETNA [1000108],AETNA [100010801],,,77.2,,14177.45576,5973.54,17514.1752,percent of total billed charges,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,63303.79,44312.653,AETNA [1000108],AETNA [100010801],,,77.2,,48870.52588,7771.48,78318.3336,percent of total billed charges,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,33293.26,23305.282,AETNA [1000108],AETNA [100010801],,,77.2,,25702.39672,7771.48,39154.1008,percent of total billed charges,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,inpatient,,,47713.27,33399.289,AETNA [1000108],AETNA [100010801],,18540,,,18540,7771.48,38170.616,case rate,
O.R. Procedures For Obesity Without Cc/McC,621,MS-DRG,,,,,,,inpatient,,,43994.97,30796.479,AETNA [1000108],AETNA [100010801],,18540,,,18540,7771.48,35195.976,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,39685.45,27779.815,AETNA [1000108],AETNA [100010801],,,77.2,,30637.1674,7771.48,75868.416,percent of total billed charges,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,19840.3,13888.21,AETNA [1000108],AETNA [100010801],,,77.2,,15316.7116,6616.74005,38785.296,percent of total billed charges,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,624,MS-DRG,,,,,,,inpatient,,,15962.42,11173.694,AETNA [1000108],AETNA [100010801],,,77.2,,12322.98824,5323.46707,20326.8184,percent of total billed charges,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,76735.34,53714.738,AETNA [1000108],AETNA [100010801],,,77.2,,59239.68248,7771.48,79967.8232,percent of total billed charges,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,36824.85,25777.395,AETNA [1000108],AETNA [100010801],,,77.2,,28428.7842,7771.48,45596.0264,percent of total billed charges,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,27285.79,19100.053,AETNA [1000108],AETNA [100010801],,,77.2,,21064.62988,7771.48,29510.4632,percent of total billed charges,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,17323.96,12126.772,AETNA [1000108],AETNA [100010801],,,77.2,,13374.09712,5777.54066,18586.1408,percent of total billed charges,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,11395.93,7977.151,AETNA [1000108],AETNA [100010801],,,77.2,,8797.65796,3800.542655,12697.4224,percent of total billed charges,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,21542.6,15079.82,AETNA [1000108],AETNA [100010801],,,77.2,,16630.8872,7184.4571,26912.6184,percent of total billed charges,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,14225.97,9958.179,AETNA [1000108],AETNA [100010801],,,77.2,,10982.44884,4744.360995,15836.316,percent of total billed charges,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,13622.93,9536.051,AETNA [1000108],AETNA [100010801],,,77.2,,10516.90196,4543.247155,25149.6504,percent of total billed charges,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,60349.49,42244.643,AETNA [1000108],AETNA [100010801],,,77.2,,46589.80628,7771.48,48279.592,percent of total billed charges,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,13236.15,9265.305,AETNA [1000108],AETNA [100010801],,,77.2,,10218.3078,4414.256025,20942.844,percent of total billed charges,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13028.88,9120.216,AETNA [1000108],AETNA [100010801],,,77.2,,10058.29536,4345.13148,15785.656,percent of total billed charges,
Major Bladder Procedures Without Cc/McC,655,MS-DRG,,,,,,,inpatient,,,55359.22,38751.454,AETNA [1000108],AETNA [100010801],,,77.2,,42737.31784,7771.48,44287.376,percent of total billed charges,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,47307.79,33115.453,AETNA [1000108],AETNA [100010801],,,77.2,,36521.61388,7771.48,66014.0328,percent of total billed charges,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,42988.03,30091.621,AETNA [1000108],AETNA [100010801],,,77.2,,33186.75916,7771.48,37042.592,percent of total billed charges,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,30491.37,21343.959,AETNA [1000108],AETNA [100010801],,,77.2,,23539.33764,7771.48,52366.2288,percent of total billed charges,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,26889.16,18822.412,AETNA [1000108],AETNA [100010801],,,77.2,,20758.43152,7771.48,27151.7336,percent of total billed charges,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,19523.55,13666.485,AETNA [1000108],AETNA [100010801],,,77.2,,15072.1806,6511.103925,20803.0224,percent of total billed charges,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,57156.94,40009.858,AETNA [1000108],AETNA [100010801],,,77.2,,44125.15768,7771.48,63211.5216,percent of total billed charges,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,29787.18,20851.026,AETNA [1000108],AETNA [100010801],,,77.2,,22995.70296,7771.48,30949.2072,percent of total billed charges,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,15013.42,10509.394,AETNA [1000108],AETNA [100010801],,,77.2,,11590.36024,5006.97557,21881.0672,percent of total billed charges,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,28865.76,20206.032,AETNA [1000108],AETNA [100010801],,,77.2,,22284.36672,7771.48,69574.4176,percent of total billed charges,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,28047.28,19633.096,AETNA [1000108],AETNA [100010801],,,77.2,,21652.50016,7771.48,33378.8608,percent of total billed charges,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,51984.11,36388.877,AETNA [1000108],AETNA [100010801],,,77.2,,40131.73292,7771.48,59091.8504,percent of total billed charges,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,30494.67,21346.269,AETNA [1000108],AETNA [100010801],,,77.2,,23541.88524,7771.48,31358.54,percent of total billed charges,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,12447.8,8713.46,AETNA [1000108],AETNA [100010801],,,77.2,,9609.7016,4151.3413,19364.2784,percent of total billed charges,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,72572.36,50800.652,AETNA [1000108],AETNA [100010801],,,77.2,,56025.86192,7771.48,84906.16,percent of total billed charges,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,49815.27,34870.689,AETNA [1000108],AETNA [100010801],,,77.2,,38457.38844,7771.48,46775.3912,percent of total billed charges,
Other Kidney And Urinary Tract Procedures Without Cc/McC,675,MS-DRG,,,,,,,inpatient,,,67065.03,46945.521,AETNA [1000108],AETNA [100010801],,,77.2,,51774.20316,7771.48,53652.024,percent of total billed charges,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25198.22,17638.754,AETNA [1000108],AETNA [100010801],,,77.2,,19453.02584,7771.48,30436.528,percent of total billed charges,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,16815.75,11771.025,AETNA [1000108],AETNA [100010801],,,77.2,,12981.759,5608.052625,18012.6696,percent of total billed charges,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,11199.54,7839.678,AETNA [1000108],AETNA [100010801],,,77.2,,8646.04488,3735.04659,12310.38,percent of total billed charges,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,17030.3,11921.21,AETNA [1000108],AETNA [100010801],,,77.2,,13147.3916,5679.60505,38209.7984,percent of total billed charges,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,10555.37,7388.759,AETNA [1000108],AETNA [100010801],,,77.2,,8148.74564,3520.215895,21329.8864,percent of total billed charges,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,21612.22,15128.554,AETNA [1000108],AETNA [100010801],,,77.2,,16684.63384,7207.67537,23716.9856,percent of total billed charges,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,14540.91,10178.637,AETNA [1000108],AETNA [100010801],,,77.2,,11225.58252,4849.393485,16263.8864,percent of total billed charges,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,27273.94,19091.758,AETNA [1000108],AETNA [100010801],,,77.2,,21055.48168,7771.48,29794.1592,percent of total billed charges,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,11406.89,7984.823,AETNA [1000108],AETNA [100010801],,,77.2,,8806.11908,3804.197815,15834.2896,percent of total billed charges,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,22314.56,15620.192,AETNA [1000108],AETNA [100010801],,,77.2,,17226.84032,7441.90576,22851.7128,percent of total billed charges,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,14767.92,10337.544,AETNA [1000108],AETNA [100010801],,,77.2,,11400.83424,4925.10132,14016.6088,percent of total billed charges,
Urethral Stricture,697,MS-DRG,,,,,,,inpatient,,,14675.76,10273.032,AETNA [1000108],AETNA [100010801],,,77.2,,11329.68672,4894.36596,20300.4752,percent of total billed charges,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,24798.67,17359.069,AETNA [1000108],AETNA [100010801],,,77.2,,19144.57324,7771.48,34061.7576,percent of total billed charges,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,17120.52,11984.364,AETNA [1000108],AETNA [100010801],,,77.2,,13217.04144,5709.69342,20665.2272,percent of total billed charges,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,41107.29,28775.103,AETNA [1000108],AETNA [100010801],,,77.2,,31734.82788,5388.92,32885.832,percent of total billed charges,
Major Male Pelvic Procedures With Cc/McC,707,MS-DRG,,,,,,,inpatient,,,35017.36,24512.152,AETNA [1000108],AETNA [100010801],,,77.2,,27033.40192,7771.48,39322.292,percent of total billed charges,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,31613.04,22129.128,AETNA [1000108],AETNA [100010801],,,77.2,,24405.26688,7771.48,30039.3536,percent of total billed charges,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,20964.14,14674.898,AETNA [1000108],AETNA [100010801],,,77.2,,16184.31608,6991.54069,45533.208,percent of total billed charges,
Penis Procedures Without Cc/McC,710,MS-DRG,,,,,,,inpatient,,,68393.44,47875.408,AETNA [1000108],AETNA [100010801],,,77.2,,52799.73568,7771.48,54714.752,percent of total billed charges,
Testes Procedures With Cc/McC,711,MS-DRG,,,,,,,inpatient,,,36907.35,25835.145,AETNA [1000108],AETNA [100010801],,,77.2,,28492.4742,7771.48,38716.3984,percent of total billed charges,
Testes Procedures Without Cc/McC,712,MS-DRG,,,,,,,inpatient,,,18463.04,12924.128,AETNA [1000108],AETNA [100010801],,,77.2,,14253.46688,6157.42384,21674.3744,percent of total billed charges,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,14941.94,10459.358,AETNA [1000108],AETNA [100010801],,,77.2,,11535.17768,4983.13699,29299.7176,percent of total billed charges,
Transurethral Prostatectomy Without Cc/McC,714,MS-DRG,,,,,,,inpatient,,,10164.77,7115.339,AETNA [1000108],AETNA [100010801],,,77.2,,7847.20244,3389.950795,19040.0544,percent of total billed charges,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC,715,MS-DRG,,,,,,,inpatient,,,36701.12,25690.784,AETNA [1000108],AETNA [100010801],,,77.2,,28333.26464,7771.48,45760.1648,percent of total billed charges,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,23580.89,16506.623,AETNA [1000108],AETNA [100010801],,,77.2,,18204.44708,7771.48,37597.8256,percent of total billed charges,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC,718,MS-DRG,,,,,,,inpatient,,,27747.61,19423.327,AETNA [1000108],AETNA [100010801],,,77.2,,21421.15492,7771.48,24961.1952,percent of total billed charges,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,48176.72,33723.704,AETNA [1000108],AETNA [100010801],,,77.2,,37192.42784,7771.48,38541.376,percent of total billed charges,
Benign Prostatic Hypertrophy With McC,725,MS-DRG,,,,,,,inpatient,,,31783.16,22248.212,AETNA [1000108],AETNA [100010801],,,77.2,,24536.59952,7771.48,25595.4584,percent of total billed charges,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,10731.22,7511.854,AETNA [1000108],AETNA [100010801],,,77.2,,8284.50184,3578.86187,15082.4952,percent of total billed charges,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,9268.85,6488.195,AETNA [1000108],AETNA [100010801],,,77.2,,7155.5522,3091.161475,16557.7144,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC,739,MS-DRG,,,,,,,inpatient,,,70791.15,49553.805,AETNA [1000108],AETNA [100010801],,,77.2,,54650.7678,7771.48,80664.9048,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,inpatient,,,61565.64,43095.948,AETNA [1000108],AETNA [100010801],,,77.2,,47528.67408,7771.48,49252.512,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC,741,MS-DRG,,,,,,,inpatient,,,66917.01,46841.907,AETNA [1000108],AETNA [100010801],,,77.2,,51659.93172,7771.48,53533.608,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,24878.38,17414.866,AETNA [1000108],AETNA [100010801],,,77.2,,19206.10936,7771.48,37014.2224,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,27909.66,19536.762,AETNA [1000108],AETNA [100010801],,,77.2,,21546.25752,7771.48,24288.4304,percent of total billed charges,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,16030.6,11221.42,AETNA [1000108],AETNA [100010801],,,77.2,,12375.6232,5346.2051,19354.1464,percent of total billed charges,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,22664.36,15865.052,AETNA [1000108],AETNA [100010801],,,77.2,,17496.88592,7558.56406,22495.0664,percent of total billed charges,
Infections- Female Reproductive System With McC,757,MS-DRG,,,,,,,inpatient,,,15549.35,10884.545,AETNA [1000108],AETNA [100010801],,,77.2,,12004.0982,5185.708225,28677.6128,percent of total billed charges,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,10151.59,7106.113,AETNA [1000108],AETNA [100010801],,,77.2,,7837.02748,3385.555265,20655.0952,percent of total billed charges,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,10881.96,7617.372,AETNA [1000108],AETNA [100010801],,,77.2,,8400.87312,3629.13366,19970.172,percent of total billed charges,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14849.95,10394.965,AETNA [1000108],AETNA [100010801],,,77.2,,11464.1614,4952.458325,13906.65298,percent of total billed charges,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,25190.93,17633.651,AETNA [1000108],AETNA [100010801],,,77.2,,19447.39796,7771.48,28156.828,percent of total billed charges,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,6415.51,4490.857,AETNA [1000108],AETNA [100010801],,,77.2,,4952.77372,2139.572585,21802.0376,percent of total billed charges,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,10227.7,7159.39,AETNA [1000108],AETNA [100010801],,,77.2,,7895.7844,3410.93795,14456.3376,percent of total billed charges,
Abortion Without D&C,779,MS-DRG,,,,,,,inpatient,,,13854.84,9698.388,AETNA [1000108],AETNA [100010801],,,77.2,,10695.93648,4620.58914,18940.7608,percent of total billed charges,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,19969.28,13978.496,AETNA [1000108],AETNA [100010801],,,77.2,,15416.28416,6659.75488,23129.64586,percent of total billed charges,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,17660.24,12362.168,AETNA [1000108],AETNA [100010801],,,77.2,,13633.70528,5889.69004,14128.192,percent of total billed charges,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,16297.53,11408.271,AETNA [1000108],AETNA [100010801],,,77.2,,12581.69316,5435.226255,13038.024,percent of total billed charges,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,19789.47,13852.629,AETNA [1000108],AETNA [100010801],,,77.2,,15277.47084,6599.788245,20332.32622,percent of total billed charges,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,17268.46,12087.922,AETNA [1000108],AETNA [100010801],,,77.2,,13331.25112,5759.03141,13814.768,percent of total billed charges,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,16414.17,11489.919,AETNA [1000108],AETNA [100010801],,,77.2,,12671.73924,5474.125695,13131.336,percent of total billed charges,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,4752.37,3326.659,AETNA [1000108],AETNA [100010801],,,77.2,,3668.82964,1584.915395,22641.16608,percent of total billed charges,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,54759.69,38331.783,AETNA [1000108],AETNA [100010801],,,77.2,,42274.48068,2909,73865.99995,percent of total billed charges,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39693.75,27785.625,AETNA [1000108],AETNA [100010801],,,77.2,,30643.575,2909,50556.23959,percent of total billed charges,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,7967.7,5577.39,AETNA [1000108],AETNA [100010801],,,77.2,,6151.0644,2657.22795,30643.57784,percent of total billed charges,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,10068.5,7047.95,AETNA [1000108],AETNA [100010801],,,77.2,,7772.882,2909,51923.98297,percent of total billed charges,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5320.51,3724.357,AETNA [1000108],AETNA [100010801],,,77.2,,4107.43372,1774.390085,18604.71546,percent of total billed charges,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4248.78,2974.146,AETNA [1000108],AETNA [100010801],,,77.2,,3280.05816,1378.34,7947.23,percent of total billed charges,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,9202.02,6441.414,AETNA [1000108],AETNA [100010801],,,77.2,,7103.95944,3068.87367,12322.49451,percent of total billed charges,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,inpatient,,,55562.6,38893.82,AETNA [1000108],AETNA [100010801],,,77.2,,42894.3272,7771.48,59041.1904,percent of total billed charges,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,36233.96,25363.772,AETNA [1000108],AETNA [100010801],,,77.2,,27972.61712,7771.48,28987.168,percent of total billed charges,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,14129.33,9890.531,AETNA [1000108],AETNA [100010801],,,77.2,,10907.84276,4712.131555,12691.01849,percent of total billed charges,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13166.38,9216.466,AETNA [1000108],AETNA [100010801],,,77.2,,10164.44536,4390.98773,10533.104,percent of total billed charges,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,12520.32,8764.224,AETNA [1000108],AETNA [100010801],,,77.2,,9665.68704,4175.52672,10016.256,percent of total billed charges,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,50163.84,35114.688,AETNA [1000108],AETNA [100010801],,,77.2,,38726.48448,7771.48,46412.6656,percent of total billed charges,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,18648.29,13053.803,AETNA [1000108],AETNA [100010801],,,77.2,,14396.47988,6219.204715,25096.964,percent of total billed charges,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,10877.8,7614.46,AETNA [1000108],AETNA [100010801],,,77.2,,8397.6616,3627.7463,19285.2488,percent of total billed charges,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,32327.52,22629.264,AETNA [1000108],AETNA [100010801],,,77.2,,24956.84544,7771.48,28507.3952,percent of total billed charges,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,22300.24,15610.168,AETNA [1000108],AETNA [100010801],,,77.2,,17215.78528,6364.97,18701.6456,percent of total billed charges,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,33797.91,23658.537,AETNA [1000108],AETNA [100010801],,,77.2,,26091.98652,7771.48,31366.6456,percent of total billed charges,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,19042.28,13329.596,AETNA [1000108],AETNA [100010801],,,77.2,,14700.64016,6350.60038,42357.8392,percent of total billed charges,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,19035.73,13325.011,AETNA [1000108],AETNA [100010801],,,77.2,,14695.58356,6348.415955,20590.2504,percent of total billed charges,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,34218.62,23953.034,AETNA [1000108],AETNA [100010801],,,77.2,,26416.77464,7771.48,51371.2664,percent of total billed charges,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,53653,37557.1,AETNA [1000108],AETNA [100010801],,,77.2,,41420.116,7771.48,45233.3008,percent of total billed charges,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,70337.4,49236.18,AETNA [1000108],AETNA [100010801],,,77.2,,54300.4728,7771.48,94819.3088,percent of total billed charges,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,inpatient,,,93776.03,65643.221,AETNA [1000108],AETNA [100010801],,,77.2,,72395.09516,7771.48,75020.824,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,73575.27,51502.689,AETNA [1000108],AETNA [100010801],,,77.2,,56800.10844,7771.48,96764.6528,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,inpatient,,,54189.56,37932.692,AETNA [1000108],AETNA [100010801],,,77.2,,41834.34032,7771.48,47816.9608,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,45890.81,32123.567,AETNA [1000108],AETNA [100010801],,,77.2,,35427.70532,7771.48,36712.648,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,19580.15,13706.105,AETNA [1000108],AETNA [100010801],,,77.2,,15115.8758,6529.980025,62486.0704,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC,830,MS-DRG,,,,,,,inpatient,,,39587.15,27711.005,AETNA [1000108],AETNA [100010801],,,77.2,,30561.2798,7771.48,31669.72,percent of total billed charges,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,19450.76,13615.532,AETNA [1000108],AETNA [100010801],,,77.2,,15015.98672,6486.82846,23321.8376,percent of total billed charges,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,17150.01,12005.007,AETNA [1000108],AETNA [100010801],,,77.2,,13239.80772,5642.16,15143.2872,percent of total billed charges,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,11361.65,7953.155,AETNA [1000108],AETNA [100010801],,,77.2,,8771.1938,3789.110275,10533.2272,percent of total billed charges,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,9828.38,6879.866,AETNA [1000108],AETNA [100010801],,,77.2,,7587.50936,3277.76473,111997.1016,percent of total billed charges,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,18619.01,13033.307,AETNA [1000108],AETNA [100010801],,,77.2,,14373.87572,6209.439835,43279.8512,percent of total billed charges,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,24808.35,17365.845,AETNA [1000108],AETNA [100010801],,,77.2,,19152.0462,7771.48,64630.0016,percent of total billed charges,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,16962.7,11873.89,AETNA [1000108],AETNA [100010801],,,77.2,,13095.2044,5657.06045,31771.9256,percent of total billed charges,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,31741.3,22218.91,AETNA [1000108],AETNA [100010801],,,77.2,,24504.2836,7771.48,25393.04,percent of total billed charges,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,19222.18,13455.526,AETNA [1000108],AETNA [100010801],,,77.2,,14839.52296,6410.59703,38361.7784,percent of total billed charges,
Radiotherapy,849,MS-DRG,,,,,,,inpatient,,,58144.26,40700.982,AETNA [1000108],AETNA [100010801],,,77.2,,44887.36872,7771.48,54123.1176,percent of total billed charges,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,85769.92,60038.944,AETNA [1000108],AETNA [100010801],,,77.2,,66214.37824,7771.48,101350.396,percent of total billed charges,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,33994.9,23796.43,AETNA [1000108],AETNA [100010801],,,77.2,,26244.0628,7771.48,40491.5248,percent of total billed charges,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65980.01,46186.007,AETNA [1000108],AETNA [100010801],,,77.2,,50936.56772,7771.48,91416.9832,percent of total billed charges,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,32658.71,22861.097,AETNA [1000108],AETNA [100010801],,,77.2,,25212.52412,7771.48,44153.2296,percent of total billed charges,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,20565.93,14396.151,AETNA [1000108],AETNA [100010801],,,77.2,,15876.89796,6858.737655,37257.3904,percent of total billed charges,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,17400.21,12180.147,AETNA [1000108],AETNA [100010801],,,77.2,,13432.96212,5802.970035,20261.9736,percent of total billed charges,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,17612.23,12328.561,AETNA [1000108],AETNA [100010801],,,77.2,,13596.64156,5873.678705,18195.0456,percent of total billed charges,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,43267.27,30287.089,AETNA [1000108],AETNA [100010801],,,77.2,,33402.33244,7771.48,34613.816,percent of total billed charges,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,18403.74,12882.618,AETNA [1000108],AETNA [100010801],,,77.2,,14207.68728,6057.47,17927.5608,percent of total billed charges,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,61414.22,42989.954,AETNA [1000108],AETNA [100010801],,,77.2,,47411.77784,7771.48,49131.376,percent of total billed charges,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,15482.04,10837.428,AETNA [1000108],AETNA [100010801],,,77.2,,11952.13488,5163.26034,21277.2,percent of total billed charges,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,13610,9527,AETNA [1000108],AETNA [100010801],,,77.2,,10506.92,4538.935,14579.948,percent of total billed charges,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,148503.39,103952.373,AETNA [1000108],AETNA [100010801],,,77.2,,114644.6171,7771.48,140966.516,percent of total billed charges,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,33194.92,23236.444,AETNA [1000108],AETNA [100010801],,,77.2,,25626.47824,7771.48,39764.0472,percent of total billed charges,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,18792.68,13154.876,AETNA [1000108],AETNA [100010801],,,77.2,,14507.94896,6267.35878,20892.184,percent of total billed charges,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,12279.31,8595.517,AETNA [1000108],AETNA [100010801],,,77.2,,9479.62732,4095.149885,19425.0704,percent of total billed charges,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,25117.86,17582.502,AETNA [1000108],AETNA [100010801],,,77.2,,19390.98792,7771.48,33842.9064,percent of total billed charges,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,22405.38,15683.766,AETNA [1000108],AETNA [100010801],,,77.2,,17296.95336,7472.19423,28562.108,percent of total billed charges,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,13917.07,9741.949,AETNA [1000108],AETNA [100010801],,,77.2,,10743.97804,3961.38,12646.7624,percent of total billed charges,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,48007.28,33605.096,AETNA [1000108],AETNA [100010801],,,77.2,,37061.62016,7771.48,38405.824,percent of total billed charges,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,20565.28,14395.696,AETNA [1000108],AETNA [100010801],,,77.2,,15876.39616,5972.81,17876.9008,percent of total billed charges,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,61408.52,42985.964,AETNA [1000108],AETNA [100010801],,,77.2,,47407.37744,7771.48,80721.644,percent of total billed charges,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,26863.69,18804.583,AETNA [1000108],AETNA [100010801],,,77.2,,20738.76868,7771.48,40872.488,percent of total billed charges,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,27835,19484.5,AETNA [1000108],AETNA [100010801],,,77.2,,21488.62,7771.48,25698.8048,percent of total billed charges,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,30162.14,21113.498,AETNA [1000108],AETNA [100010801],,,77.2,,23285.17208,7771.48,32791.2048,percent of total billed charges,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42212,29548.4,AETNA [1000108],AETNA [100010801],,,77.2,,32587.664,7771.48,35214.7792,percent of total billed charges,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,17347.78,12143.446,AETNA [1000108],AETNA [100010801],,,77.2,,13392.48616,4755.82,13878.224,percent of total billed charges,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,43962.28,30773.596,AETNA [1000108],AETNA [100010801],,,77.2,,33938.88016,7771.48,35169.824,percent of total billed charges,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,17818.34,12472.838,AETNA [1000108],AETNA [100010801],,,77.2,,13755.75848,5723.92,17921.4816,percent of total billed charges,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,31482.85,22037.995,AETNA [1000108],AETNA [100010801],,,77.2,,24304.7602,7771.48,36949.3776,percent of total billed charges,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,15673.65,10971.555,AETNA [1000108],AETNA [100010801],,,77.2,,12100.0578,5227.162275,20584.1712,percent of total billed charges,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,7247.46,5073.222,AETNA [1000108],AETNA [100010801],,,77.2,,5595.03912,2417.02791,13933.5264,percent of total billed charges,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,28001.68,19601.176,AETNA [1000108],AETNA [100010801],,,77.2,,21617.29696,6731.81,22401.344,percent of total billed charges,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC,939,MS-DRG,,,,,,,inpatient,,,23950.54,16765.378,AETNA [1000108],AETNA [100010801],,,77.2,,18489.81688,7771.48,64313.8832,percent of total billed charges,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,49540.17,34678.119,AETNA [1000108],AETNA [100010801],,,77.2,,38245.01124,7771.48,42783.3832,percent of total billed charges,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC,941,MS-DRG,,,,,,,inpatient,,,17064.75,11945.325,AETNA [1000108],AETNA [100010801],,,77.2,,13173.987,5691.094125,39599.9088,percent of total billed charges,
Rehabilitation With Cc/McC,945,MS-DRG,,,,,,,inpatient,,,45131.85,31592.295,AETNA [1000108],AETNA [100010801],,,77.2,,34841.7882,7771.48,36105.48,percent of total billed charges,
Rehabilitation Without Cc/McC,946,MS-DRG,,,,,,,inpatient,,,44615.43,31230.801,AETNA [1000108],AETNA [100010801],,,77.2,,34443.11196,7771.48,35692.344,percent of total billed charges,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,22069.35,15448.545,AETNA [1000108],AETNA [100010801],,,77.2,,17037.5382,7360.128225,26061.5304,percent of total billed charges,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,17906.41,12534.487,AETNA [1000108],AETNA [100010801],,,77.2,,13823.74852,5684.12,16099.748,percent of total billed charges,
Aftercare With Cc/McC,949,MS-DRG,,,,,,,inpatient,,,33492.73,23444.911,AETNA [1000108],AETNA [100010801],,,77.2,,25856.38756,7771.48,26794.184,percent of total billed charges,
Aftercare Without Cc/McC,950,MS-DRG,,,,,,,inpatient,,,9898.64,6929.048,AETNA [1000108],AETNA [100010801],,,77.2,,7641.75008,3301.19644,11876.7304,percent of total billed charges,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,4337.06,3035.942,AETNA [1000108],AETNA [100010801],,,77.2,,3348.21032,1446.40951,11487.6616,percent of total billed charges,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,61892.75,43324.925,AETNA [1000108],AETNA [100010801],,,77.2,,47781.203,7771.48,77453.0608,percent of total billed charges,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,12905.91,9034.137,AETNA [1000108],AETNA [100010801],,,77.2,,9963.36252,4304.120985,30400.0528,percent of total billed charges,
Other Multiple Significant Trauma Without Cc/McC,965,MS-DRG,,,,,,,inpatient,,,19234.18,13463.926,AETNA [1000108],AETNA [100010801],,,77.2,,14848.78696,6414.59903,18490.9,percent of total billed charges,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,37958.81,26571.167,AETNA [1000108],AETNA [100010801],,,77.2,,29304.20132,7771.48,60508.304,percent of total billed charges,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,12545.67,8781.969,AETNA [1000108],AETNA [100010801],,,77.2,,9685.25724,4183.980945,29216.6352,percent of total billed charges,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,108861.48,76203.036,AETNA [1000108],AETNA [100010801],,,77.2,,84041.06256,7771.48,96341.1352,percent of total billed charges,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,62893.24,44025.268,AETNA [1000108],AETNA [100010801],,,77.2,,48553.58128,7771.48,50314.592,percent of total billed charges,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,59507.83,41655.481,AETNA [1000108],AETNA [100010801],,,77.2,,45940.04476,7771.48,47606.264,percent of total billed charges,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51559.92,36091.944,AETNA [1000108],AETNA [100010801],,,77.2,,39804.25824,7771.48,70984.792,percent of total billed charges,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,16279.53,11395.671,AETNA [1000108],AETNA [100010801],,,77.2,,12567.79716,5429.223255,34773.024,percent of total billed charges,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,989,MS-DRG,,,,,,,inpatient,,,64497.43,45148.201,AETNA [1000108],AETNA [100010801],,,77.2,,49792.01596,7771.48,51597.944,percent of total billed charges,
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,inpatient,,,7296.22,5107.354,AETNA [1000108],AETNA [100010801],,,77.2,,5632.68184,2433.28937,7947.23,percent of total billed charges,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,AETNA [1000108],AETNA [100010801],,,76.8,,60.672,17.7355,1592,percent of total billed charges,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA [1000108],AETNA [100010801],,,76.8,,1625.09,399.86,2141,percent of total billed charges,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,AETNA [1000108],AETNA [100010801],,,76.8,,198.14,57.921,1592,percent of total billed charges,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,AETNA [1000108],AETNA [100010801],,,76.8,,668.93,195.5395,1592,percent of total billed charges,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,AETNA [1000108],AETNA [100010801],,,76.8,,531.46,155.354,2141,percent of total billed charges,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,AETNA [1000108],AETNA [100010801],,,76.8,,1428.48,291.227805,2141,percent of total billed charges,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,AETNA [1000108],AETNA [100010801],,,76.8,,99.84,29.185,1592,percent of total billed charges,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,AETNA [1000108],AETNA [100010801],,,76.8,,708.1,206.989,1592,percent of total billed charges,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,AETNA [1000108],AETNA [100010801],,,76.8,,708.1,206.989,1592,percent of total billed charges,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,AETNA [1000108],AETNA [100010801],,,76.8,,3715.58,399.86,3715.584,percent of total billed charges,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,AETNA [1000108],AETNA [100010801],,,76.8,,703.49,205.642,1592,percent of total billed charges,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,AETNA [1000108],AETNA [100010801],,,76.8,,703.49,205.642,1592,percent of total billed charges,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,AETNA [1000108],AETNA [100010801],,,76.8,,6635.52,399.86,6635.52,percent of total billed charges,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,AETNA [1000108],AETNA [100010801],,,76.8,,901.63,263.563,1592,percent of total billed charges,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,AETNA [1000108],AETNA [100010801],,,76.8,,40.7,11.8985,1592,percent of total billed charges,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,AETNA [1000108],AETNA [100010801],,,76.8,,1563.65,399.86,2998,percent of total billed charges,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,AETNA [1000108],AETNA [100010801],,,76.8,,1536.77,399.86,2998,percent of total billed charges,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,AETNA [1000108],AETNA [100010801],,,76.8,,1393.92,399.86,2998,percent of total billed charges,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,AETNA [1000108],AETNA [100010801],,,76.8,,542.21,158.497,3914,percent of total billed charges,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,AETNA [1000108],AETNA [100010801],,,76.8,,1622.78,399.86,2141,percent of total billed charges,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,AETNA [1000108],AETNA [100010801],,,76.8,,1687.3,399.86,2141,percent of total billed charges,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,AETNA [1000108],AETNA [100010801],,,76.8,,781.82,228.541,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,AETNA [1000108],AETNA [100010801],,,76.8,,817.92,239.0925,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,AETNA [1000108],AETNA [100010801],,,76.8,,2172.67,399.86,2477.315575,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,AETNA [1000108],AETNA [100010801],,,76.8,,923.9,270.0735,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,AETNA [1000108],AETNA [100010801],,,76.8,,923.9,270.0735,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,AETNA [1000108],AETNA [100010801],,,76.8,,1466.88,399.86,1592,percent of total billed charges,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,62.19,1592,percent of total billed charges,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,66.75974,1592,percent of total billed charges,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,AETNA [1000108],AETNA [100010801],,,76.8,,162.82,47.594,1592,percent of total billed charges,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,AETNA [1000108],AETNA [100010801],,,76.8,,331.01,96.7595,1592,percent of total billed charges,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,AETNA [1000108],AETNA [100010801],,,76.8,,106.75,31.2055,1592,percent of total billed charges,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,35.6955,1592,percent of total billed charges,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,AETNA [1000108],AETNA [100010801],,,76.8,,1469.95,399.86,1592,percent of total billed charges,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,AETNA [1000108],AETNA [100010801],,,76.8,,1687.3,399.86,2141,percent of total billed charges,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,113.876282,1592,percent of total billed charges,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,AETNA [1000108],AETNA [100010801],,,76.8,,1057.54,156.65,1592,percent of total billed charges,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,AETNA [1000108],AETNA [100010801],,,76.8,,387.84,113.3725,1592,percent of total billed charges,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,AETNA [1000108],AETNA [100010801],,,76.8,,387.84,113.3725,1592,percent of total billed charges,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,AETNA [1000108],AETNA [100010801],,,76.8,,341.76,99.9025,1592,percent of total billed charges,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,AETNA [1000108],AETNA [100010801],,,76.8,,393.98,115.1685,1592,percent of total billed charges,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,AETNA [1000108],AETNA [100010801],,,76.8,,497.66,145.476,1592,percent of total billed charges,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,AETNA [1000108],AETNA [100010801],,,76.8,,326.4,95.4125,1592,percent of total billed charges,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,AETNA [1000108],AETNA [100010801],,,76.8,,252.67,73.8605,1592,percent of total billed charges,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,AETNA [1000108],AETNA [100010801],,,76.8,,307.2,89.8,1592,percent of total billed charges,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,AETNA [1000108],AETNA [100010801],,,76.8,,367.87,107.5355,1592,percent of total billed charges,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,AETNA [1000108],AETNA [100010801],,,76.8,,486.14,142.1085,1592,percent of total billed charges,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,76.8,,598.27,174.8855,1592,percent of total billed charges,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,AETNA [1000108],AETNA [100010801],,,76.8,,426.24,124.5975,1592,percent of total billed charges,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,76.8,,344.06,100.576,1592,percent of total billed charges,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,AETNA [1000108],AETNA [100010801],,,76.8,,1057.54,309.1365,1592,percent of total billed charges,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,AETNA [1000108],AETNA [100010801],,,76.8,,621.31,181.6205,1592,percent of total billed charges,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,AETNA [1000108],AETNA [100010801],,,76.8,,684.29,200.0295,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,AETNA [1000108],AETNA [100010801],,,76.8,,387.84,113.3725,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,AETNA [1000108],AETNA [100010801],,,76.8,,526.08,153.7825,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,AETNA [1000108],AETNA [100010801],,,76.8,,526.08,153.7825,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,AETNA [1000108],AETNA [100010801],,,76.8,,498.43,145.7005,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA [1000108],AETNA [100010801],,,76.8,,3459.07,399.86,3459.072,percent of total billed charges,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,AETNA [1000108],AETNA [100010801],,,76.8,,486.91,142.333,1592,percent of total billed charges,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,AETNA [1000108],AETNA [100010801],,,76.8,,486.14,142.1085,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,AETNA [1000108],AETNA [100010801],,,76.8,,478.46,139.8635,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,AETNA [1000108],AETNA [100010801],,,76.8,,481.54,140.7615,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,AETNA [1000108],AETNA [100010801],,,76.8,,811.01,237.072,2141,percent of total billed charges,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,AETNA [1000108],AETNA [100010801],,,76.8,,4022.78,399.86,4022.784,percent of total billed charges,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,AETNA [1000108],AETNA [100010801],,,76.8,,684.29,200.0295,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,AETNA [1000108],AETNA [100010801],,,76.8,,457.73,133.802,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,AETNA [1000108],AETNA [100010801],,,76.8,,509.18,148.8435,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,AETNA [1000108],AETNA [100010801],,,76.8,,500.74,146.374,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,AETNA [1000108],AETNA [100010801],,,76.8,,575.23,168.1505,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,AETNA [1000108],AETNA [100010801],,,76.8,,1089.79,318.5655,1592,percent of total billed charges,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,AETNA [1000108],AETNA [100010801],,,76.8,,869.38,254.134,1592,percent of total billed charges,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,AETNA [1000108],AETNA [100010801],,,76.8,,1406.21,399.86,1592,percent of total billed charges,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,AETNA [1000108],AETNA [100010801],,,76.8,,837.12,244.705,1592,percent of total billed charges,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,AETNA [1000108],AETNA [100010801],,,76.8,,192,56.125,1592,percent of total billed charges,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,AETNA [1000108],AETNA [100010801],,,76.8,,1352.45,395.3445,1592,percent of total billed charges,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,AETNA [1000108],AETNA [100010801],,,76.8,,564.48,165.0075,1592,percent of total billed charges,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,AETNA [1000108],AETNA [100010801],,,76.8,,234.24,68.4725,1592,percent of total billed charges,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,AETNA [1000108],AETNA [100010801],,,76.8,,879.36,257.0525,1592,percent of total billed charges,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,AETNA [1000108],AETNA [100010801],,,76.8,,555.26,162.3135,1592,percent of total billed charges,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,AETNA [1000108],AETNA [100010801],,,76.8,,443.9,129.761,1592,percent of total billed charges,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,AETNA [1000108],AETNA [100010801],,,76.8,,1352.45,395.3445,1592,percent of total billed charges,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,AETNA [1000108],AETNA [100010801],,,76.8,,570.62,166.8035,1592,percent of total billed charges,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,AETNA [1000108],AETNA [100010801],,,76.8,,354.82,103.719,1592,percent of total billed charges,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA [1000108],AETNA [100010801],,,76.8,,3459.07,399.86,3459.072,percent of total billed charges,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,AETNA [1000108],AETNA [100010801],,,76.8,,1406.21,108.7,1592,percent of total billed charges,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,AETNA [1000108],AETNA [100010801],,,76.8,,2630.4,399.86,4341.777195,percent of total billed charges,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA [1000108],AETNA [100010801],,,76.8,,5804.54,399.86,5804.544,percent of total billed charges,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,AETNA [1000108],AETNA [100010801],,,76.8,,7323.65,399.86,7323.648,percent of total billed charges,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,AETNA [1000108],AETNA [100010801],,,76.8,,4478.21,399.86,4478.208,percent of total billed charges,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA [1000108],AETNA [100010801],,,76.8,,5804.54,399.86,5804.544,percent of total billed charges,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,AETNA [1000108],AETNA [100010801],,,76.8,,4478.21,399.86,5481.863562,percent of total billed charges,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,AETNA [1000108],AETNA [100010801],,,76.8,,7323.65,399.86,7323.648,percent of total billed charges,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA [1000108],AETNA [100010801],,,76.8,,5804.54,399.86,5804.544,percent of total billed charges,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,AETNA [1000108],AETNA [100010801],,,76.8,,301.82,88.2285,1592,percent of total billed charges,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,AETNA [1000108],AETNA [100010801],,,76.8,,623.62,182.294,1592,percent of total billed charges,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,AETNA [1000108],AETNA [100010801],,,76.8,,623.62,182.294,1592,percent of total billed charges,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,1592,percent of total billed charges,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,AETNA [1000108],AETNA [100010801],,,76.8,,514.56,150.415,2998,percent of total billed charges,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,AETNA [1000108],AETNA [100010801],,,76.8,,1353.98,395.7935,1592,percent of total billed charges,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA [1000108],AETNA [100010801],,,76.8,,1257.22,367.5065,2141,percent of total billed charges,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,76.8,,46.08,13.47,1592,percent of total billed charges,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,AETNA [1000108],AETNA [100010801],,,76.8,,3315.46,399.86,3315.456,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,AETNA [1000108],AETNA [100010801],,,76.8,,3070.46,399.86,3070.464,percent of total billed charges,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,AETNA [1000108],AETNA [100010801],,,76.8,,2512.13,399.86,2998,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,AETNA [1000108],AETNA [100010801],,,76.8,,1794.05,399.86,1794.048,percent of total billed charges,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,AETNA [1000108],AETNA [100010801],,,76.8,,3932.16,399.86,3932.16,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,AETNA [1000108],AETNA [100010801],,,76.8,,1714.18,399.86,1714.176,percent of total billed charges,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,108.7,2998,percent of total billed charges,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,AETNA [1000108],AETNA [100010801],,,76.8,,675.84,197.56,1592,percent of total billed charges,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA [1000108],AETNA [100010801],,,76.8,,1625.09,108.7,2141,percent of total billed charges,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,AETNA [1000108],AETNA [100010801],,,76.8,,64.51,18.858,1592,percent of total billed charges,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,AETNA [1000108],AETNA [100010801],,,76.8,,902.4,108.7,2141,percent of total billed charges,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,AETNA [1000108],AETNA [100010801],,,76.8,,210.43,61.513,1592,percent of total billed charges,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA [1000108],AETNA [100010801],,,76.8,,1625.09,108.7,2141,percent of total billed charges,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,AETNA [1000108],AETNA [100010801],,,76.8,,10786.56,399.86,14403.82399,percent of total billed charges,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,AETNA [1000108],AETNA [100010801],,,76.8,,2954.5,399.86,2954.496,percent of total billed charges,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,AETNA [1000108],AETNA [100010801],,,76.8,,1114.37,235.074116,1592,percent of total billed charges,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA [1000108],AETNA [100010801],,,76.8,,4007.42,399.86,4007.424,percent of total billed charges,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,AETNA [1000108],AETNA [100010801],,,76.8,,4449.02,399.86,4449.024,percent of total billed charges,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,AETNA [1000108],AETNA [100010801],,,76.8,,632.06,184.7635,1592,percent of total billed charges,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,AETNA [1000108],AETNA [100010801],,,76.8,,693.5,202.7235,1592,percent of total billed charges,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,1592,percent of total billed charges,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,AETNA [1000108],AETNA [100010801],,,76.8,,548.35,160.293,1592,percent of total billed charges,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,AETNA [1000108],AETNA [100010801],,,76.8,,548.35,160.293,1592,percent of total billed charges,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,AETNA [1000108],AETNA [100010801],,,76.8,,720.38,210.581,1592,percent of total billed charges,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,AETNA [1000108],AETNA [100010801],,,76.8,,578.3,169.0485,1592,percent of total billed charges,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,AETNA [1000108],AETNA [100010801],,,76.8,,578.3,169.0485,1592,percent of total billed charges,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,AETNA [1000108],AETNA [100010801],,,76.8,,1416.19,399.86,2141,percent of total billed charges,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,1592,percent of total billed charges,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,1592,percent of total billed charges,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,AETNA [1000108],AETNA [100010801],,,76.8,,602.11,176.008,1592,percent of total billed charges,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,AETNA [1000108],AETNA [100010801],,,76.8,,12651.26,399.86,20110.10933,percent of total billed charges,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,AETNA [1000108],AETNA [100010801],,,76.8,,3683.33,399.86,3683.328,percent of total billed charges,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,AETNA [1000108],AETNA [100010801],,,76.8,,1301.76,380.5275,1592,percent of total billed charges,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,AETNA [1000108],AETNA [100010801],,,76.8,,1921.54,399.86,2477.315575,percent of total billed charges,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,AETNA [1000108],AETNA [100010801],,,76.8,,855.55,235.074116,1592,percent of total billed charges,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,AETNA [1000108],AETNA [100010801],,,76.8,,564.48,165.0075,1592,percent of total billed charges,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,AETNA [1000108],AETNA [100010801],,,76.8,,2767.87,399.86,2998,percent of total billed charges,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA [1000108],AETNA [100010801],,,76.8,,4007.42,399.86,4341.777195,percent of total billed charges,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,AETNA [1000108],AETNA [100010801],,,76.8,,2566.66,399.86,2998,percent of total billed charges,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA [1000108],AETNA [100010801],,,76.8,,4007.42,399.86,4007.424,percent of total billed charges,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,AETNA [1000108],AETNA [100010801],,,76.8,,940.03,274.788,1592,percent of total billed charges,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA [1000108],AETNA [100010801],,,76.8,,3826.94,399.86,3826.944,percent of total billed charges,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,AETNA [1000108],AETNA [100010801],,,76.8,,16604.93,399.86,16604.928,percent of total billed charges,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA [1000108],AETNA [100010801],,,76.8,,4007.42,399.86,4007.424,percent of total billed charges,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,AETNA [1000108],AETNA [100010801],,,76.8,,1274.88,235.074116,1592,percent of total billed charges,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,AETNA [1000108],AETNA [100010801],,,76.8,,1968.38,399.86,2455.793921,percent of total billed charges,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,AETNA [1000108],AETNA [100010801],,,76.8,,1968.38,399.86,2998,percent of total billed charges,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA [1000108],AETNA [100010801],,,76.8,,3826.94,399.86,3826.944,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA [1000108],AETNA [100010801],,,76.8,,3826.94,399.86,3826.944,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA [1000108],AETNA [100010801],,,76.8,,3826.94,399.86,3826.944,percent of total billed charges,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2841.6,percent of total billed charges,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2841.6,percent of total billed charges,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,AETNA [1000108],AETNA [100010801],,,76.8,,1220.35,235.074116,1592,percent of total billed charges,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,AETNA [1000108],AETNA [100010801],,,76.8,,2687.23,399.86,2998,percent of total billed charges,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,AETNA [1000108],AETNA [100010801],,,76.8,,692.74,202.499,1592,percent of total billed charges,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,AETNA [1000108],AETNA [100010801],,,76.8,,2187.26,399.86,2455.793921,percent of total billed charges,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,AETNA [1000108],AETNA [100010801],,,76.8,,515.33,150.6395,1592,percent of total billed charges,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,AETNA [1000108],AETNA [100010801],,,76.8,,1570.56,399.86,2998,percent of total billed charges,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,AETNA [1000108],AETNA [100010801],,,76.8,,549.12,160.5175,1592,percent of total billed charges,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,AETNA [1000108],AETNA [100010801],,,76.8,,5885.18,399.86,5885.184,percent of total billed charges,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,AETNA [1000108],AETNA [100010801],,,76.8,,1110.53,324.627,1592,percent of total billed charges,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,AETNA [1000108],AETNA [100010801],,,76.8,,640.51,187.233,1592,percent of total billed charges,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,AETNA [1000108],AETNA [100010801],,,76.8,,2813.18,292.65,2813.184,percent of total billed charges,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,AETNA [1000108],AETNA [100010801],,,76.8,,509.95,149.068,1592,percent of total billed charges,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,AETNA [1000108],AETNA [100010801],,,76.8,,685.82,200.4785,1592,percent of total billed charges,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,AETNA [1000108],AETNA [100010801],,,76.8,,377.09,110.2295,1592,percent of total billed charges,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,AETNA [1000108],AETNA [100010801],,,76.8,,392.45,114.7195,1592,percent of total billed charges,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,AETNA [1000108],AETNA [100010801],,,76.8,,347.9,101.6985,1592,percent of total billed charges,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,1592,percent of total billed charges,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,1592,percent of total billed charges,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,AETNA [1000108],AETNA [100010801],,,76.8,,169.73,49.6145,1592,percent of total billed charges,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,AETNA [1000108],AETNA [100010801],,,76.8,,167.42,48.941,1592,percent of total billed charges,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,AETNA [1000108],AETNA [100010801],,,76.8,,311.04,90.9225,1592,percent of total billed charges,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,AETNA [1000108],AETNA [100010801],,,76.8,,93.7,27.389,1592,percent of total billed charges,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,AETNA [1000108],AETNA [100010801],,,76.8,,93.7,27.389,1592,percent of total billed charges,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,AETNA [1000108],AETNA [100010801],,,76.8,,536.83,156.9255,1592,percent of total billed charges,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,AETNA [1000108],AETNA [100010801],,,76.8,,425.47,124.373,1592,percent of total billed charges,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,1592,percent of total billed charges,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,77.9015,1592,percent of total billed charges,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,77.9015,1592,percent of total billed charges,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,AETNA [1000108],AETNA [100010801],,,76.8,,221.95,64.8805,1592,percent of total billed charges,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,AETNA [1000108],AETNA [100010801],,,76.8,,221.95,64.8805,1592,percent of total billed charges,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,76.8,,373.25,109.107,1592,percent of total billed charges,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,AETNA [1000108],AETNA [100010801],,,76.8,,391.68,114.495,1592,percent of total billed charges,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,AETNA [1000108],AETNA [100010801],,,76.8,,417.79,122.128,1592,percent of total billed charges,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,AETNA [1000108],AETNA [100010801],,,76.8,,417.79,122.128,1592,percent of total billed charges,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,AETNA [1000108],AETNA [100010801],,,76.8,,417.79,122.128,1592,percent of total billed charges,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,AETNA [1000108],AETNA [100010801],,,76.8,,472.32,138.0675,1592,percent of total billed charges,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,AETNA [1000108],AETNA [100010801],,,76.8,,284.93,83.2895,1592,percent of total billed charges,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,AETNA [1000108],AETNA [100010801],,,76.8,,2419.97,399.86,2998,percent of total billed charges,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,AETNA [1000108],AETNA [100010801],,,76.8,,2419.2,399.86,2998,percent of total billed charges,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,AETNA [1000108],AETNA [100010801],,,76.8,,3022.08,399.86,3022.08,percent of total billed charges,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,AETNA [1000108],AETNA [100010801],,,76.8,,2512.13,399.86,2998,percent of total billed charges,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,AETNA [1000108],AETNA [100010801],,,76.8,,3528.19,399.86,3528.192,percent of total billed charges,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA [1000108],AETNA [100010801],,,76.8,,6425.86,399.86,6425.856,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,AETNA [1000108],AETNA [100010801],,,76.8,,1498.37,399.86,2447.133941,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,AETNA [1000108],AETNA [100010801],,,76.8,,1498.37,399.86,2447.133941,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,AETNA [1000108],AETNA [100010801],,,76.8,,1498.37,399.86,2447.133941,percent of total billed charges,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,AETNA [1000108],AETNA [100010801],,,76.8,,1498.37,399.86,2447.133941,percent of total billed charges,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,AETNA [1000108],AETNA [100010801],,,76.8,,1739.52,399.86,2141,percent of total billed charges,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,AETNA [1000108],AETNA [100010801],,,76.8,,3224.06,399.86,3224.064,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,AETNA [1000108],AETNA [100010801],,,76.8,,1439.23,399.86,2141,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,AETNA [1000108],AETNA [100010801],,,76.8,,1256.45,367.282,2141,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,AETNA [1000108],AETNA [100010801],,,76.8,,1256.45,367.282,2141,percent of total billed charges,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,AETNA [1000108],AETNA [100010801],,,76.8,,2224.13,399.86,2998,percent of total billed charges,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,AETNA [1000108],AETNA [100010801],,,76.8,,1445.38,399.86,2447.133941,percent of total billed charges,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,AETNA [1000108],AETNA [100010801],,,76.8,,1739.52,399.86,1739.52,percent of total billed charges,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA [1000108],AETNA [100010801],,,76.8,,1091.33,319.0145,2141,percent of total billed charges,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA [1000108],AETNA [100010801],,,76.8,,1091.33,319.0145,2141,percent of total billed charges,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,AETNA [1000108],AETNA [100010801],,,76.8,,4252.42,399.86,4252.416,percent of total billed charges,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,AETNA [1000108],AETNA [100010801],,,76.8,,4252.42,399.86,4252.416,percent of total billed charges,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,AETNA [1000108],AETNA [100010801],,,76.8,,28237.06,399.86,28237.056,percent of total billed charges,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA [1000108],AETNA [100010801],,,76.8,,16478.21,399.86,16478.208,percent of total billed charges,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA [1000108],AETNA [100010801],,,76.8,,16478.21,399.86,16478.208,percent of total billed charges,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,AETNA [1000108],AETNA [100010801],,,76.8,,3094.27,399.86,4870.452937,percent of total billed charges,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA [1000108],AETNA [100010801],,,76.8,,16478.21,399.86,16478.208,percent of total billed charges,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,AETNA [1000108],AETNA [100010801],,,76.8,,37615.87,399.86,37615.872,percent of total billed charges,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA [1000108],AETNA [100010801],,,76.8,,3459.07,399.86,3459.072,percent of total billed charges,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,AETNA [1000108],AETNA [100010801],,,76.8,,2085.89,399.86,2998,percent of total billed charges,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,AETNA [1000108],AETNA [100010801],,,76.8,,5814.53,399.86,6364,percent of total billed charges,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,AETNA [1000108],AETNA [100010801],,,76.8,,2798.59,399.86,4870.452937,percent of total billed charges,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,AETNA [1000108],AETNA [100010801],,,76.8,,13659.65,399.86,13659.648,percent of total billed charges,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,AETNA [1000108],AETNA [100010801],,,76.8,,15092.74,399.86,16316.30039,percent of total billed charges,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,AETNA [1000108],AETNA [100010801],,,76.8,,17342.98,399.86,29773.2518,percent of total billed charges,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,AETNA [1000108],AETNA [100010801],,,76.8,,51836.93,399.86,51836.928,percent of total billed charges,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,AETNA [1000108],AETNA [100010801],,,76.8,,49918.46,399.86,50269.54813,percent of total billed charges,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA [1000108],AETNA [100010801],,,76.8,,16478.21,399.86,16478.208,percent of total billed charges,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,AETNA [1000108],AETNA [100010801],,,76.8,,6933.5,399.86,6933.504,percent of total billed charges,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,AETNA [1000108],AETNA [100010801],,,76.8,,66342.91,399.86,66342.912,percent of total billed charges,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,AETNA [1000108],AETNA [100010801],,,76.8,,48388.61,399.86,48388.608,percent of total billed charges,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,AETNA [1000108],AETNA [100010801],,,76.8,,50497.54,399.86,50497.536,percent of total billed charges,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,AETNA [1000108],AETNA [100010801],,,76.8,,50497.54,399.86,50497.536,percent of total billed charges,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA [1000108],AETNA [100010801],,,76.8,,21295.1,399.86,21295.104,percent of total billed charges,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA [1000108],AETNA [100010801],,,76.8,,21295.1,399.86,21295.104,percent of total billed charges,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,22573.824,percent of total billed charges,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,22573.824,percent of total billed charges,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA [1000108],AETNA [100010801],,,76.8,,21295.1,399.86,23502.2528,percent of total billed charges,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,24913.5068,percent of total billed charges,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,24913.5068,percent of total billed charges,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,AETNA [1000108],AETNA [100010801],,,76.8,,5338.37,399.86,5338.368,percent of total billed charges,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,AETNA [1000108],AETNA [100010801],,,76.8,,4584.96,399.86,4584.96,percent of total billed charges,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,AETNA [1000108],AETNA [100010801],,,76.8,,3394.56,399.86,3746.392,percent of total billed charges,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,AETNA [1000108],AETNA [100010801],,,76.8,,1266.43,370.2005,2998,percent of total billed charges,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,AETNA [1000108],AETNA [100010801],,,76.8,,2933.76,399.86,3237.832,percent of total billed charges,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,AETNA [1000108],AETNA [100010801],,,76.8,,3220.99,399.86,3220.992,percent of total billed charges,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,AETNA [1000108],AETNA [100010801],,,76.8,,1382.4,399.86,2998,percent of total billed charges,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,AETNA [1000108],AETNA [100010801],,,76.8,,1929.98,399.86,6913,percent of total billed charges,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,AETNA [1000108],AETNA [100010801],,,76.8,,106.75,31.2055,6913,percent of total billed charges,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,AETNA [1000108],AETNA [100010801],,,76.8,,3155.71,399.86,3155.712,percent of total billed charges,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA [1000108],AETNA [100010801],,,76.8,,3216.38,399.86,3549.7488,percent of total billed charges,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA [1000108],AETNA [100010801],,,76.8,,3216.38,399.86,3549.7488,percent of total billed charges,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,AETNA [1000108],AETNA [100010801],,,76.8,,3155.71,399.86,3155.712,percent of total billed charges,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA [1000108],AETNA [100010801],,,76.8,,3216.38,293.5896,3216.384,percent of total billed charges,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,AETNA [1000108],AETNA [100010801],,,76.8,,1359.36,397.365,2141,percent of total billed charges,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,AETNA [1000108],AETNA [100010801],,,76.8,,1359.36,397.365,2141,percent of total billed charges,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,AETNA [1000108],AETNA [100010801],,,76.8,,116.74,34.124,2998,percent of total billed charges,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,AETNA [1000108],AETNA [100010801],,,76.8,,182.78,53.431,2998,percent of total billed charges,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,AETNA [1000108],AETNA [100010801],,,76.8,,128.26,37.4915,2998,percent of total billed charges,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,AETNA [1000108],AETNA [100010801],,,76.8,,258.82,75.6565,2998,percent of total billed charges,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,76.8,,343.3,100.3515,2998,percent of total billed charges,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,AETNA [1000108],AETNA [100010801],,,76.8,,167.42,48.941,2998,percent of total billed charges,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,AETNA [1000108],AETNA [100010801],,,76.8,,263.42,77.0035,1592,percent of total billed charges,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,AETNA [1000108],AETNA [100010801],,,76.8,,595.2,173.9875,2141,percent of total billed charges,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,AETNA [1000108],AETNA [100010801],,,76.8,,198.14,57.921,1592,percent of total billed charges,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,76.8,,415.49,121.4545,1592,percent of total billed charges,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,AETNA [1000108],AETNA [100010801],,,76.8,,593.66,173.5385,1592,percent of total billed charges,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,204.0705,1592,percent of total billed charges,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,AETNA [1000108],AETNA [100010801],,,76.8,,6398.21,399.86,6398.208,percent of total billed charges,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,AETNA [1000108],AETNA [100010801],,,76.8,,553.73,161.8645,1592,percent of total billed charges,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,AETNA [1000108],AETNA [100010801],,,76.8,,1276.42,373.119,1592,percent of total billed charges,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,AETNA [1000108],AETNA [100010801],,,76.8,,482.3,140.986,1592,percent of total billed charges,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,AETNA [1000108],AETNA [100010801],,,76.8,,261.12,76.33,1592,percent of total billed charges,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,AETNA [1000108],AETNA [100010801],,,76.8,,2003.71,399.86,2003.712,percent of total billed charges,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,AETNA [1000108],AETNA [100010801],,,76.8,,553.73,161.8645,1592,percent of total billed charges,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,AETNA [1000108],AETNA [100010801],,,76.8,,791.04,231.235,1592,percent of total billed charges,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,AETNA [1000108],AETNA [100010801],,,76.8,,436.22,127.516,1592,percent of total billed charges,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,AETNA [1000108],AETNA [100010801],,,76.8,,1186.56,346.8525,1592,percent of total billed charges,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,AETNA [1000108],AETNA [100010801],,,76.8,,83.71,24.4705,1592,percent of total billed charges,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,AETNA [1000108],AETNA [100010801],,,76.8,,7442.69,399.86,7442.688,percent of total billed charges,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,AETNA [1000108],AETNA [100010801],,,76.8,,7442.69,399.86,7442.688,percent of total billed charges,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,AETNA [1000108],AETNA [100010801],,,76.8,,7020.29,399.86,8396.844904,percent of total billed charges,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,AETNA [1000108],AETNA [100010801],,,76.8,,12170.5,399.86,12170.496,percent of total billed charges,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,AETNA [1000108],AETNA [100010801],,,76.8,,7020.29,399.86,7020.288,percent of total billed charges,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,AETNA [1000108],AETNA [100010801],,,76.8,,12170.5,399.86,12170.496,percent of total billed charges,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,AETNA [1000108],AETNA [100010801],,,76.8,,395.52,115.6175,1592,percent of total billed charges,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,AETNA [1000108],AETNA [100010801],,,76.8,,470.02,137.394,1592,percent of total billed charges,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,AETNA [1000108],AETNA [100010801],,,76.8,,850.18,248.5215,1592,percent of total billed charges,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,AETNA [1000108],AETNA [100010801],,,76.8,,949.25,277.482,1592,percent of total billed charges,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,AETNA [1000108],AETNA [100010801],,,76.8,,1107.46,323.729,1592,percent of total billed charges,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,AETNA [1000108],AETNA [100010801],,,76.8,,198.14,57.921,1592,percent of total billed charges,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,AETNA [1000108],AETNA [100010801],,,76.8,,7242.24,399.86,7242.24,percent of total billed charges,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,AETNA [1000108],AETNA [100010801],,,76.8,,7242.24,399.86,7242.24,percent of total billed charges,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,AETNA [1000108],AETNA [100010801],,,76.8,,7242.24,399.86,8396.844904,percent of total billed charges,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,AETNA [1000108],AETNA [100010801],,,76.8,,7242.24,399.86,7242.24,percent of total billed charges,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,AETNA [1000108],AETNA [100010801],,,76.8,,18.43,5.388,416.02,percent of total billed charges,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,AETNA [1000108],AETNA [100010801],,,,,,207.2135,1592,other,Rev 391 at $0
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,156.65,1592,percent of total billed charges,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,204.0705,1592,percent of total billed charges,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,AETNA [1000108],AETNA [100010801],,,76.8,,294.14,85.9835,1592,percent of total billed charges,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,6623.08,percent of total billed charges,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,AETNA [1000108],AETNA [100010801],,,76.8,,1380.1,399.86,1592,percent of total billed charges,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,AETNA [1000108],AETNA [100010801],,,76.8,,1380.1,399.86,1592,percent of total billed charges,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,1592,percent of total billed charges,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,76.8,,316.42,92.494,1592,percent of total billed charges,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,AETNA [1000108],AETNA [100010801],,,76.8,,593.66,173.5385,1592,percent of total billed charges,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,AETNA [1000108],AETNA [100010801],,,76.8,,1026.82,300.1565,2081.64,percent of total billed charges,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,AETNA [1000108],AETNA [100010801],,,76.8,,3777.79,399.86,3777.792,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,6012.672,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,6012.672,percent of total billed charges,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,AETNA [1000108],AETNA [100010801],,,76.8,,6012.67,399.86,6012.672,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2953.728,percent of total billed charges,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,AETNA [1000108],AETNA [100010801],,,76.8,,2953.73,399.86,2953.728,percent of total billed charges,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA [1000108],AETNA [100010801],,,76.8,,1091.33,319.0145,2141,percent of total billed charges,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA [1000108],AETNA [100010801],,,76.8,,1091.33,319.0145,2141,percent of total billed charges,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2998,percent of total billed charges,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,AETNA [1000108],AETNA [100010801],,,76.8,,122.88,35.92,1592,percent of total billed charges,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,AETNA [1000108],AETNA [100010801],,,76.8,,96,28.0625,1592,percent of total billed charges,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,AETNA [1000108],AETNA [100010801],,,76.8,,619.01,180.947,1592,percent of total billed charges,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,AETNA [1000108],AETNA [100010801],,,76.8,,311.81,91.147,1592,percent of total billed charges,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,AETNA [1000108],AETNA [100010801],,,76.8,,228.1,66.6765,1592,percent of total billed charges,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,AETNA [1000108],AETNA [100010801],,,76.8,,237.31,69.3705,1592,percent of total billed charges,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,AETNA [1000108],AETNA [100010801],,,76.8,,8219.14,399.86,9071.0152,percent of total billed charges,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,AETNA [1000108],AETNA [100010801],,,76.8,,436.22,127.516,1592,percent of total billed charges,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,AETNA [1000108],AETNA [100010801],,,76.8,,436.22,127.516,1592,percent of total billed charges,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,AETNA [1000108],AETNA [100010801],,,76.8,,3164.16,399.86,5756,percent of total billed charges,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,AETNA [1000108],AETNA [100010801],,,76.8,,10010.88,399.86,18955.84,percent of total billed charges,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,26793.51305,percent of total billed charges,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,AETNA [1000108],AETNA [100010801],,,76.8,,632.83,184.988,4800.911611,percent of total billed charges,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,AETNA [1000108],AETNA [100010801],,,76.8,,949.25,277.482,8164.18419,percent of total billed charges,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,6788.57,percent of total billed charges,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,AETNA [1000108],AETNA [100010801],,,76.8,,10775.04,399.86,10775.04,percent of total billed charges,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,AETNA [1000108],AETNA [100010801],,,76.8,,7394.3,399.86,7394.304,percent of total billed charges,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,AETNA [1000108],AETNA [100010801],,,76.8,,7678.46,399.86,7678.464,percent of total billed charges,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,AETNA [1000108],AETNA [100010801],,,76.8,,470.78,137.6185,1592,percent of total billed charges,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,AETNA [1000108],AETNA [100010801],,,76.8,,6777.6,399.86,6777.6,percent of total billed charges,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,AETNA [1000108],AETNA [100010801],,,76.8,,2487.55,399.86,4870.452937,percent of total billed charges,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,AETNA [1000108],AETNA [100010801],,,76.8,,5548.03,399.86,5548.032,percent of total billed charges,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,AETNA [1000108],AETNA [100010801],,,76.8,,5548.03,399.86,5548.032,percent of total billed charges,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,AETNA [1000108],AETNA [100010801],,,76.8,,424.7,124.1485,2998,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,AETNA [1000108],AETNA [100010801],,,76.8,,12283.39,399.86,12283.392,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,AETNA [1000108],AETNA [100010801],,,76.8,,12746.5,399.86,18955.84,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,AETNA [1000108],AETNA [100010801],,,76.8,,12148.22,399.86,12148.224,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,AETNA [1000108],AETNA [100010801],,,76.8,,12453.89,399.86,12453.888,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,AETNA [1000108],AETNA [100010801],,,76.8,,12748.03,399.86,12748.032,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,AETNA [1000108],AETNA [100010801],,,76.8,,26165.76,399.86,26793.51305,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,AETNA [1000108],AETNA [100010801],,,76.8,,25020.67,399.86,25020.672,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,AETNA [1000108],AETNA [100010801],,,76.8,,45315.84,399.86,45315.84,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,AETNA [1000108],AETNA [100010801],,,76.8,,12287.23,399.86,16809.6787,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,AETNA [1000108],AETNA [100010801],,,76.8,,26777.09,399.86,26793.51305,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,AETNA [1000108],AETNA [100010801],,,76.8,,26165.76,399.86,26793.51305,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,AETNA [1000108],AETNA [100010801],,,76.8,,44656.13,399.86,44656.128,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,AETNA [1000108],AETNA [100010801],,,76.8,,12327.94,399.86,12327.936,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,AETNA [1000108],AETNA [100010801],,,76.8,,25786.37,399.86,25786.368,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,AETNA [1000108],AETNA [100010801],,,76.8,,12327.94,399.86,12327.936,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,AETNA [1000108],AETNA [100010801],,,76.8,,12148.22,399.86,12148.224,percent of total billed charges,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,AETNA [1000108],AETNA [100010801],,,76.8,,3055.1,399.86,4532,percent of total billed charges,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,AETNA [1000108],AETNA [100010801],,,76.8,,3055.1,399.86,4532,percent of total billed charges,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,26793.51305,percent of total billed charges,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,AETNA [1000108],AETNA [100010801],,,76.8,,3565.82,399.86,3565.824,percent of total billed charges,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,AETNA [1000108],AETNA [100010801],,,76.8,,292.61,85.5345,1592,percent of total billed charges,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,AETNA [1000108],AETNA [100010801],,,76.8,,1515.26,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,AETNA [1000108],AETNA [100010801],,,76.8,,1515.26,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,AETNA [1000108],AETNA [100010801],,,76.8,,1514.5,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,AETNA [1000108],AETNA [100010801],,,76.8,,1514.5,399.86,2477.315575,percent of total billed charges,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,AETNA [1000108],AETNA [100010801],,,76.8,,3573.5,399.86,4341.777195,percent of total billed charges,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,AETNA [1000108],AETNA [100010801],,,76.8,,3573.5,399.86,4341.777195,percent of total billed charges,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,AETNA [1000108],AETNA [100010801],,,76.8,,1515.26,399.86,2998,percent of total billed charges,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,AETNA [1000108],AETNA [100010801],,,76.8,,384,112.25,1592,percent of total billed charges,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,AETNA [1000108],AETNA [100010801],,,76.8,,414.72,121.23,1592,percent of total billed charges,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,AETNA [1000108],AETNA [100010801],,,76.8,,1995.26,399.86,2477.315575,percent of total billed charges,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA [1000108],AETNA [100010801],,,76.8,,1257.22,367.5065,2141,percent of total billed charges,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,AETNA [1000108],AETNA [100010801],,,76.8,,325.63,95.188,1592,percent of total billed charges,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,AETNA [1000108],AETNA [100010801],,,76.8,,409.34,119.6585,1592,percent of total billed charges,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,AETNA [1000108],AETNA [100010801],,,76.8,,526.08,153.7825,1592,percent of total billed charges,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,AETNA [1000108],AETNA [100010801],,,76.8,,249.6,72.9625,1592,percent of total billed charges,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,AETNA [1000108],AETNA [100010801],,,76.8,,249.6,72.9625,1592,percent of total billed charges,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,AETNA [1000108],AETNA [100010801],,,76.8,,444.67,129.9855,1592,percent of total billed charges,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,AETNA [1000108],AETNA [100010801],,,76.8,,380.93,111.352,1592,percent of total billed charges,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,AETNA [1000108],AETNA [100010801],,,76.8,,675.07,197.3355,1592,percent of total billed charges,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,AETNA [1000108],AETNA [100010801],,,76.8,,675.07,197.3355,1592,percent of total billed charges,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,AETNA [1000108],AETNA [100010801],,,76.8,,1284.86,375.5885,2998,percent of total billed charges,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,AETNA [1000108],AETNA [100010801],,,76.8,,2094.34,399.86,4005.9,percent of total billed charges,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,AETNA [1000108],AETNA [100010801],,,76.8,,4934.4,399.86,4934.4,percent of total billed charges,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,AETNA [1000108],AETNA [100010801],,,76.8,,2853.89,399.86,2998,percent of total billed charges,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,AETNA [1000108],AETNA [100010801],,,76.8,,746.5,218.214,1592,percent of total billed charges,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA [1000108],AETNA [100010801],,,76.8,,10219.78,399.86,10219.776,percent of total billed charges,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA [1000108],AETNA [100010801],,,76.8,,6425.86,399.86,6425.856,percent of total billed charges,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA [1000108],AETNA [100010801],,,76.8,,6425.86,399.86,6425.856,percent of total billed charges,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA [1000108],AETNA [100010801],,,76.8,,10219.78,399.86,15728.70471,percent of total billed charges,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,AETNA [1000108],AETNA [100010801],,,76.8,,1336.32,390.63,2998,percent of total billed charges,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,AETNA [1000108],AETNA [100010801],,,76.8,,6577.15,399.86,6577.152,percent of total billed charges,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,AETNA [1000108],AETNA [100010801],,,76.8,,6577.15,399.86,6577.152,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,AETNA [1000108],AETNA [100010801],,,76.8,,710.4,207.6625,2998,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,AETNA [1000108],AETNA [100010801],,,76.8,,1255.68,367.0575,2998,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,AETNA [1000108],AETNA [100010801],,,76.8,,1255.68,367.0575,2998,percent of total billed charges,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA [1000108],AETNA [100010801],,,76.8,,6425.86,399.86,6425.856,percent of total billed charges,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,AETNA [1000108],AETNA [100010801],,,76.8,,2204.16,399.86,2998,percent of total billed charges,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,AETNA [1000108],AETNA [100010801],,,76.8,,2032.9,399.86,2998,percent of total billed charges,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,AETNA [1000108],AETNA [100010801],,,76.8,,6116.35,399.86,6116.352,percent of total billed charges,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA [1000108],AETNA [100010801],,,76.8,,3280.13,399.86,3280.128,percent of total billed charges,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,AETNA [1000108],AETNA [100010801],,,76.8,,377.09,110.2295,1592,percent of total billed charges,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA [1000108],AETNA [100010801],,,76.8,,3280.13,399.86,3280.128,percent of total billed charges,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA [1000108],AETNA [100010801],,,76.8,,3280.13,399.86,3280.128,percent of total billed charges,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,AETNA [1000108],AETNA [100010801],,,76.8,,1262.59,369.078,2998,percent of total billed charges,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,AETNA [1000108],AETNA [100010801],,,76.8,,1262.59,369.078,2998,percent of total billed charges,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,AETNA [1000108],AETNA [100010801],,,76.8,,1299.46,379.854,2998,percent of total billed charges,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,AETNA [1000108],AETNA [100010801],,,76.8,,1299.46,379.854,2998,percent of total billed charges,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,AETNA [1000108],AETNA [100010801],,,76.8,,2009.86,399.86,2998,percent of total billed charges,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,AETNA [1000108],AETNA [100010801],,,76.8,,2009.86,399.86,2998,percent of total billed charges,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,AETNA [1000108],AETNA [100010801],,,76.8,,1634.3,399.86,2998,percent of total billed charges,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,AETNA [1000108],AETNA [100010801],,,76.8,,465.41,136.047,1592,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,AETNA [1000108],AETNA [100010801],,,76.8,,38.62,1.160665,416.02,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,AETNA [1000108],AETNA [100010801],,,76.8,,3.97,1.160665,416.02,percent of total billed charges,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,4179.83,percent of total billed charges,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,AETNA [1000108],AETNA [100010801],,,76.8,,1161.98,339.6685,2141,percent of total billed charges,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,AETNA [1000108],AETNA [100010801],,,76.8,,557.57,162.987,2141,percent of total billed charges,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,AETNA [1000108],AETNA [100010801],,,76.8,,409.34,119.6585,1592,percent of total billed charges,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,AETNA [1000108],AETNA [100010801],,,76.8,,1161.98,334.48,2141,percent of total billed charges,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,AETNA [1000108],AETNA [100010801],,,76.8,,4225.54,399.86,4225.536,percent of total billed charges,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA [1000108],AETNA [100010801],,,76.8,,8911.1,399.86,8911.104,percent of total billed charges,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA [1000108],AETNA [100010801],,,76.8,,10219.78,399.86,10219.776,percent of total billed charges,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,AETNA [1000108],AETNA [100010801],,,76.8,,287.23,83.963,1592,percent of total billed charges,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,AETNA [1000108],AETNA [100010801],,,76.8,,409.34,119.6585,1592,percent of total billed charges,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA [1000108],AETNA [100010801],,,76.8,,8911.1,399.86,8911.104,percent of total billed charges,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA [1000108],AETNA [100010801],,,76.8,,8911.1,399.86,8911.104,percent of total billed charges,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,AETNA [1000108],AETNA [100010801],,,76.8,,536.83,156.9255,1592,percent of total billed charges,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,AETNA [1000108],AETNA [100010801],,,76.8,,536.83,156.9255,1592,percent of total billed charges,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,AETNA [1000108],AETNA [100010801],,,76.8,,1857.79,179.53,2998,percent of total billed charges,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,AETNA [1000108],AETNA [100010801],,,76.8,,1857.79,179.53,2998,percent of total billed charges,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,AETNA [1000108],AETNA [100010801],,,76.8,,1117.44,235.074116,1592,percent of total billed charges,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,AETNA [1000108],AETNA [100010801],,,76.8,,749.57,219.112,1592,percent of total billed charges,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,AETNA [1000108],AETNA [100010801],,,76.8,,675.07,197.3355,1592,percent of total billed charges,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,AETNA [1000108],AETNA [100010801],,,76.8,,298.75,87.3305,1592,percent of total billed charges,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,AETNA [1000108],AETNA [100010801],,,76.8,,300.29,87.7795,1592,percent of total billed charges,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,1592,percent of total billed charges,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,AETNA [1000108],AETNA [100010801],,,76.8,,350.21,102.372,1592,percent of total billed charges,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,AETNA [1000108],AETNA [100010801],,,76.8,,364.8,106.6375,1592,percent of total billed charges,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,AETNA [1000108],AETNA [100010801],,,76.8,,162.82,47.594,1592,percent of total billed charges,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,AETNA [1000108],AETNA [100010801],,,76.8,,6210.05,399.86,6210.048,percent of total billed charges,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,AETNA [1000108],AETNA [100010801],,,76.8,,5068.03,399.86,5068.032,percent of total billed charges,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,AETNA [1000108],AETNA [100010801],,,76.8,,453.89,120.28264,1592,percent of total billed charges,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,AETNA [1000108],AETNA [100010801],,,76.8,,636.67,186.1105,1592,percent of total billed charges,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,AETNA [1000108],AETNA [100010801],,,76.8,,3849.98,399.86,4777.053449,percent of total billed charges,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,AETNA [1000108],AETNA [100010801],,,76.8,,838.66,235.074116,1592,percent of total billed charges,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,AETNA [1000108],AETNA [100010801],,,76.8,,5299.2,399.86,5299.2,percent of total billed charges,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,AETNA [1000108],AETNA [100010801],,,76.8,,376.32,110.005,416.02,percent of total billed charges,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,AETNA [1000108],AETNA [100010801],,,76.8,,2351.62,399.86,4777.053449,percent of total billed charges,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,AETNA [1000108],AETNA [100010801],,,76.8,,5511.17,399.86,5511.168,percent of total billed charges,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,AETNA [1000108],AETNA [100010801],,,76.8,,1162.75,339.893,2141,percent of total billed charges,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,AETNA [1000108],AETNA [100010801],,,76.8,,4634.88,399.86,11413.04,percent of total billed charges,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,AETNA [1000108],AETNA [100010801],,,76.8,,1447.68,399.86,2141,percent of total billed charges,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,AETNA [1000108],AETNA [100010801],,,76.8,,409.34,119.6585,5756,percent of total billed charges,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA [1000108],AETNA [100010801],,,76.8,,1257.22,367.5065,2141,percent of total billed charges,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,2141,percent of total billed charges,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,2141,percent of total billed charges,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,2141,percent of total billed charges,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,AETNA [1000108],AETNA [100010801],,,76.8,,964.61,281.972,2141,percent of total billed charges,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,AETNA [1000108],AETNA [100010801],,,76.8,,964.61,281.972,2141,percent of total billed charges,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,2141,percent of total billed charges,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,AETNA [1000108],AETNA [100010801],,,76.8,,1007.62,294.544,1592,percent of total billed charges,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,AETNA [1000108],AETNA [100010801],,,76.8,,4841.47,399.86,6224.0876,percent of total billed charges,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,AETNA [1000108],AETNA [100010801],,,76.8,,964.61,281.972,1592,percent of total billed charges,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,AETNA [1000108],AETNA [100010801],,,76.8,,850.18,248.5215,1592,percent of total billed charges,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,AETNA [1000108],AETNA [100010801],,,76.8,,1986.05,399.86,2141,percent of total billed charges,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,AETNA [1000108],AETNA [100010801],,,76.8,,630.53,155.844464,1592,percent of total billed charges,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,AETNA [1000108],AETNA [100010801],,,76.8,,684.29,200.0295,1592,percent of total billed charges,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,AETNA [1000108],AETNA [100010801],,,76.8,,1254.91,323.2601,1592,percent of total billed charges,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,AETNA [1000108],AETNA [100010801],,,76.8,,673.54,196.8865,1592,percent of total billed charges,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,AETNA [1000108],AETNA [100010801],,,76.8,,1061.38,310.259,2141,percent of total billed charges,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,AETNA [1000108],AETNA [100010801],,,76.8,,4677.12,399.86,4677.12,percent of total billed charges,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,AETNA [1000108],AETNA [100010801],,,76.8,,1254.91,366.833,2141,percent of total billed charges,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,AETNA [1000108],AETNA [100010801],,,76.8,,633.6,185.2125,1592,percent of total billed charges,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,AETNA [1000108],AETNA [100010801],,,76.8,,176.64,51.635,1592,percent of total billed charges,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,AETNA [1000108],AETNA [100010801],,,76.8,,319.49,93.392,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,AETNA [1000108],AETNA [100010801],,,76.8,,169.73,49.6145,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,AETNA [1000108],AETNA [100010801],,,76.8,,172.03,50.288,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,AETNA [1000108],AETNA [100010801],,,76.8,,41.47,12.123,1592,percent of total billed charges,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,AETNA [1000108],AETNA [100010801],,,76.8,,1662.72,399.86,2141,percent of total billed charges,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,AETNA [1000108],AETNA [100010801],,,76.8,,527.62,154.2315,1592,percent of total billed charges,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,AETNA [1000108],AETNA [100010801],,,76.8,,527.62,154.2315,1592,percent of total billed charges,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,AETNA [1000108],AETNA [100010801],,,76.8,,157.44,46.0225,1592,percent of total billed charges,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,AETNA [1000108],AETNA [100010801],,,76.8,,234.24,66.75974,1592,percent of total billed charges,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,AETNA [1000108],AETNA [100010801],,,76.8,,208.13,60.8395,416.02,percent of total billed charges,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,AETNA [1000108],AETNA [100010801],,,76.8,,456.96,71.24,456.96,percent of total billed charges,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,AETNA [1000108],AETNA [100010801],,,76.8,,375.55,76.026473,416.02,percent of total billed charges,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,AETNA [1000108],AETNA [100010801],,,76.8,,294.91,86.208,416.02,percent of total billed charges,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,AETNA [1000108],AETNA [100010801],,,76.8,,226.56,66.2275,416.02,percent of total billed charges,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,AETNA [1000108],AETNA [100010801],,,76.8,,258.05,71.24,416.02,percent of total billed charges,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,AETNA [1000108],AETNA [100010801],,,76.8,,193.54,56.574,416.02,percent of total billed charges,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,AETNA [1000108],AETNA [100010801],,,76.8,,244.99,71.24,416.02,percent of total billed charges,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,AETNA [1000108],AETNA [100010801],,,76.8,,251.9,73.636,416.02,percent of total billed charges,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,AETNA [1000108],AETNA [100010801],,,76.8,,251.9,71.24,416.02,percent of total billed charges,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,AETNA [1000108],AETNA [100010801],,,76.8,,340.99,71.24,416.02,percent of total billed charges,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,416.02,percent of total billed charges,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,76.026473,416.02,percent of total billed charges,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,AETNA [1000108],AETNA [100010801],,,76.8,,321.79,76.026473,416.02,percent of total billed charges,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,AETNA [1000108],AETNA [100010801],,,76.8,,549.89,71.24,549.888,percent of total billed charges,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,AETNA [1000108],AETNA [100010801],,,76.8,,1987.58,267.439885,1987.584,percent of total billed charges,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,AETNA [1000108],AETNA [100010801],,,76.8,,178.18,52.084,416.02,percent of total billed charges,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,416.02,percent of total billed charges,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,AETNA [1000108],AETNA [100010801],,,76.8,,412.42,120.5565,646.6965,percent of total billed charges,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,AETNA [1000108],AETNA [100010801],,,76.8,,821.76,89.81,821.76,percent of total billed charges,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,AETNA [1000108],AETNA [100010801],,,76.8,,1023.74,124.33,1023.744,percent of total billed charges,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,AETNA [1000108],AETNA [100010801],,,76.8,,1240.32,153.75,1240.32,percent of total billed charges,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,AETNA [1000108],AETNA [100010801],,,76.8,,504.58,96.160741,575,percent of total billed charges,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,AETNA [1000108],AETNA [100010801],,,76.8,,594.43,173.763,667.43,percent of total billed charges,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,AETNA [1000108],AETNA [100010801],,,76.8,,1243.39,200.53123,1243.392,percent of total billed charges,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,76.8,,921.6,96.160741,921.6,percent of total billed charges,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,AETNA [1000108],AETNA [100010801],,,76.8,,1014.53,200.53123,1014.528,percent of total billed charges,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,AETNA [1000108],AETNA [100010801],,,76.8,,889.34,200.53123,889.344,percent of total billed charges,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,AETNA [1000108],AETNA [100010801],,,76.8,,394.75,96.160741,575,percent of total billed charges,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,AETNA [1000108],AETNA [100010801],,,76.8,,1138.18,194.55,1138.176,percent of total billed charges,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,AETNA [1000108],AETNA [100010801],,,76.8,,1347.84,200.53123,1347.84,percent of total billed charges,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,AETNA [1000108],AETNA [100010801],,,76.8,,1021.44,200.53123,1021.44,percent of total billed charges,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,AETNA [1000108],AETNA [100010801],,,76.8,,888.58,200.53123,888.576,percent of total billed charges,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,AETNA [1000108],AETNA [100010801],,,76.8,,3902.21,237.688956,3902.208,percent of total billed charges,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,AETNA [1000108],AETNA [100010801],,,76.8,,2081.28,365.99,2081.28,percent of total billed charges,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,AETNA [1000108],AETNA [100010801],,,76.8,,1299.46,379.854,1299.456,percent of total billed charges,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA [1000108],AETNA [100010801],,,76.8,,1750.27,267.439885,1750.272,percent of total billed charges,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA [1000108],AETNA [100010801],,,76.8,,1750.27,374.62,1750.272,percent of total billed charges,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA [1000108],AETNA [100010801],,,76.8,,1750.27,301.425681,1750.272,percent of total billed charges,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,AETNA [1000108],AETNA [100010801],,,76.8,,1675.78,267.439885,1675.776,percent of total billed charges,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,AETNA [1000108],AETNA [100010801],,,76.8,,1896.19,399.86,1896.192,percent of total billed charges,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,AETNA [1000108],AETNA [100010801],,,76.8,,1946.11,301.425681,1946.112,percent of total billed charges,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,AETNA [1000108],AETNA [100010801],,,76.8,,1605.12,188.66,1605.12,percent of total billed charges,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,AETNA [1000108],AETNA [100010801],,,76.8,,4035.84,268.7,4035.84,percent of total billed charges,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,AETNA [1000108],AETNA [100010801],,,76.8,,2049.02,307.14,2049.024,percent of total billed charges,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,AETNA [1000108],AETNA [100010801],,,76.8,,164.35,48.043,416.02,percent of total billed charges,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,AETNA [1000108],AETNA [100010801],,,76.8,,178.18,52.084,416.02,percent of total billed charges,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,AETNA [1000108],AETNA [100010801],,,76.8,,188.16,55.0025,416.02,percent of total billed charges,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,AETNA [1000108],AETNA [100010801],,,76.8,,314.88,76.026473,416.02,percent of total billed charges,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,AETNA [1000108],AETNA [100010801],,,76.8,,371.71,76.026473,416.02,percent of total billed charges,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,AETNA [1000108],AETNA [100010801],,,76.8,,431.62,76.026473,431.616,percent of total billed charges,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,71.24,416.02,percent of total billed charges,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,AETNA [1000108],AETNA [100010801],,,76.8,,192,56.125,416.02,percent of total billed charges,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,AETNA [1000108],AETNA [100010801],,,76.8,,1065.98,96.160741,1065.984,percent of total billed charges,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,AETNA [1000108],AETNA [100010801],,,76.8,,1247.23,195.34,1247.232,percent of total billed charges,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,AETNA [1000108],AETNA [100010801],,,76.8,,1522.18,200.53123,1522.176,percent of total billed charges,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,AETNA [1000108],AETNA [100010801],,,76.8,,202.75,59.268,575,percent of total billed charges,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,AETNA [1000108],AETNA [100010801],,,76.8,,1222.66,200.53123,1222.656,percent of total billed charges,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,AETNA [1000108],AETNA [100010801],,,76.8,,1519.87,237.688956,1519.872,percent of total billed charges,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,AETNA [1000108],AETNA [100010801],,,76.8,,2402.3,399.86,2402.304,percent of total billed charges,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,AETNA [1000108],AETNA [100010801],,,76.8,,1188.1,347.3015,1288.93,percent of total billed charges,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA [1000108],AETNA [100010801],,,76.8,,1817.86,301.425681,1817.856,percent of total billed charges,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA [1000108],AETNA [100010801],,,76.8,,1817.86,301.425681,1817.856,percent of total billed charges,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA [1000108],AETNA [100010801],,,76.8,,1817.86,301.425681,1817.856,percent of total billed charges,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,AETNA [1000108],AETNA [100010801],,,76.8,,192.77,56.3495,416.02,percent of total billed charges,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,AETNA [1000108],AETNA [100010801],,,76.8,,227.33,66.452,416.02,percent of total billed charges,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,AETNA [1000108],AETNA [100010801],,,76.8,,230.4,67.35,416.02,percent of total billed charges,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,AETNA [1000108],AETNA [100010801],,,76.8,,230.4,67.35,416.02,percent of total billed charges,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,AETNA [1000108],AETNA [100010801],,,76.8,,193.54,56.574,416.02,percent of total billed charges,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,76.8,,217.34,63.5335,416.02,percent of total billed charges,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,76.8,,235.01,68.697,416.02,percent of total billed charges,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,71.24,416.02,percent of total billed charges,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,AETNA [1000108],AETNA [100010801],,,76.8,,295.68,86.4325,416.02,percent of total billed charges,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,AETNA [1000108],AETNA [100010801],,,76.8,,581.38,119.991125,581.376,percent of total billed charges,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,AETNA [1000108],AETNA [100010801],,,76.8,,581.38,76.026473,581.376,percent of total billed charges,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,AETNA [1000108],AETNA [100010801],,,76.8,,180.48,52.7575,416.02,percent of total billed charges,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,AETNA [1000108],AETNA [100010801],,,76.8,,248.06,72.5135,416.02,percent of total billed charges,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,AETNA [1000108],AETNA [100010801],,,76.8,,462.34,76.026473,462.336,percent of total billed charges,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,AETNA [1000108],AETNA [100010801],,,76.8,,315.65,92.2695,416.02,percent of total billed charges,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,AETNA [1000108],AETNA [100010801],,,76.8,,1043.71,96.160741,1043.712,percent of total billed charges,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,AETNA [1000108],AETNA [100010801],,,76.8,,1195.01,196.52,1195.008,percent of total billed charges,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,AETNA [1000108],AETNA [100010801],,,76.8,,1719.55,200.53123,1719.552,percent of total billed charges,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,96.160741,698.112,percent of total billed charges,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,AETNA [1000108],AETNA [100010801],,,76.8,,796.42,196.52,796.416,percent of total billed charges,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,AETNA [1000108],AETNA [100010801],,,76.8,,1704.19,200.53123,1704.192,percent of total billed charges,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,AETNA [1000108],AETNA [100010801],,,76.8,,528.38,96.160741,575,percent of total billed charges,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,AETNA [1000108],AETNA [100010801],,,76.8,,1095.94,195.73,1095.936,percent of total billed charges,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,AETNA [1000108],AETNA [100010801],,,76.8,,1057.54,200.53123,1057.536,percent of total billed charges,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,AETNA [1000108],AETNA [100010801],,,76.8,,1624.32,185.92,1624.32,percent of total billed charges,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,AETNA [1000108],AETNA [100010801],,,76.8,,2337.02,270.27,2337.024,percent of total billed charges,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,AETNA [1000108],AETNA [100010801],,,76.8,,1706.5,185.92,1706.496,percent of total billed charges,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,AETNA [1000108],AETNA [100010801],,,76.8,,2183.42,266.73,2183.424,percent of total billed charges,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,AETNA [1000108],AETNA [100010801],,,76.8,,2035.97,185.92,2035.968,percent of total billed charges,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,AETNA [1000108],AETNA [100010801],,,76.8,,2031.36,265.17,2031.36,percent of total billed charges,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,AETNA [1000108],AETNA [100010801],,,76.8,,2399.23,307.53,2399.232,percent of total billed charges,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,AETNA [1000108],AETNA [100010801],,,76.8,,2175.74,307.93,2175.744,percent of total billed charges,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,AETNA [1000108],AETNA [100010801],,,76.8,,2443.01,305.58,2443.008,percent of total billed charges,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,76.8,,220.42,64.4315,416.02,percent of total billed charges,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,AETNA [1000108],AETNA [100010801],,,76.8,,974.59,200.53123,974.592,percent of total billed charges,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,AETNA [1000108],AETNA [100010801],,,76.8,,1050.62,96.160741,1050.624,percent of total billed charges,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,AETNA [1000108],AETNA [100010801],,,76.8,,1198.85,195.33,1198.848,percent of total billed charges,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,AETNA [1000108],AETNA [100010801],,,76.8,,1460.74,200.53123,1460.736,percent of total billed charges,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,AETNA [1000108],AETNA [100010801],,,76.8,,1721.09,237.688956,1721.088,percent of total billed charges,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,AETNA [1000108],AETNA [100010801],,,76.8,,2188.8,372.27,2188.8,percent of total billed charges,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,AETNA [1000108],AETNA [100010801],,,76.8,,2114.3,399.547552,2114.304,percent of total billed charges,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,AETNA [1000108],AETNA [100010801],,,76.8,,2233.34,399.86,2233.344,percent of total billed charges,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,AETNA [1000108],AETNA [100010801],,,76.8,,2081.28,399.86,2233.344,percent of total billed charges,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,AETNA [1000108],AETNA [100010801],,,76.8,,1402.37,399.86,2233.344,percent of total billed charges,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,AETNA [1000108],AETNA [100010801],,,76.8,,340.22,76.026473,416.02,percent of total billed charges,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,AETNA [1000108],AETNA [100010801],,,76.8,,258.05,71.24,416.02,percent of total billed charges,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,AETNA [1000108],AETNA [100010801],,,76.8,,1135.1,331.811,2051.3855,percent of total billed charges,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,AETNA [1000108],AETNA [100010801],,,76.8,,1400.06,399.86,2051.3855,percent of total billed charges,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,AETNA [1000108],AETNA [100010801],,,76.8,,1351.68,395.12,2051.3855,percent of total billed charges,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,AETNA [1000108],AETNA [100010801],,,76.8,,1400.06,399.86,2051.3855,percent of total billed charges,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,AETNA [1000108],AETNA [100010801],,,76.8,,3307.01,399.86,4977.9345,percent of total billed charges,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,AETNA [1000108],AETNA [100010801],,,76.8,,3307.01,399.86,4977.9345,percent of total billed charges,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,AETNA [1000108],AETNA [100010801],,,76.8,,130.56,38.165,416.02,percent of total billed charges,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,76.8,,235.01,68.697,416.02,percent of total billed charges,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,AETNA [1000108],AETNA [100010801],,,76.8,,196.61,57.472,416.02,percent of total billed charges,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,AETNA [1000108],AETNA [100010801],,,76.8,,106.75,31.2055,416.02,percent of total billed charges,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,AETNA [1000108],AETNA [100010801],,,76.8,,1297.92,379.405,1297.92,percent of total billed charges,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,AETNA [1000108],AETNA [100010801],,,76.8,,248.06,71.24,416.02,percent of total billed charges,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,AETNA [1000108],AETNA [100010801],,,76.8,,136.7,39.961,416.02,percent of total billed charges,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,AETNA [1000108],AETNA [100010801],,,76.8,,131.33,38.3895,416.02,percent of total billed charges,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,AETNA [1000108],AETNA [100010801],,,76.8,,99.07,28.9605,416.02,percent of total billed charges,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,AETNA [1000108],AETNA [100010801],,,76.8,,1022.21,298.8095,1022.208,percent of total billed charges,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,AETNA [1000108],AETNA [100010801],,,76.8,,172.8,50.5125,416.02,percent of total billed charges,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,AETNA [1000108],AETNA [100010801],,,76.8,,282.62,76.026473,416.02,percent of total billed charges,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,AETNA [1000108],AETNA [100010801],,,76.8,,145.92,42.655,416.02,percent of total billed charges,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,AETNA [1000108],AETNA [100010801],,,76.8,,1322.5,237.819698,1322.496,percent of total billed charges,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,76.8,,235.01,68.697,416.02,percent of total billed charges,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,AETNA [1000108],AETNA [100010801],,,76.8,,181.25,52.982,416.02,percent of total billed charges,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,AETNA [1000108],AETNA [100010801],,,76.8,,99.07,28.9605,416.02,percent of total billed charges,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,AETNA [1000108],AETNA [100010801],,,76.8,,736.51,96.160741,736.512,percent of total billed charges,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,AETNA [1000108],AETNA [100010801],,,76.8,,1065.98,193.37,1065.984,percent of total billed charges,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,AETNA [1000108],AETNA [100010801],,,76.8,,1506.05,200.53123,1506.048,percent of total billed charges,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,AETNA [1000108],AETNA [100010801],,,76.8,,1032.96,200.53123,1032.96,percent of total billed charges,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,AETNA [1000108],AETNA [100010801],,,76.8,,2217.98,237.688956,2217.984,percent of total billed charges,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,AETNA [1000108],AETNA [100010801],,,76.8,,2254.85,371.09,2254.848,percent of total billed charges,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,AETNA [1000108],AETNA [100010801],,,76.8,,2414.59,399.547552,2414.592,percent of total billed charges,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,AETNA [1000108],AETNA [100010801],,,76.8,,2333.95,204.76,2333.952,percent of total billed charges,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,AETNA [1000108],AETNA [100010801],,,76.8,,2414.59,340.49,2414.592,percent of total billed charges,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,AETNA [1000108],AETNA [100010801],,,76.8,,2350.08,399.547552,2350.08,percent of total billed charges,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,49.839,416.02,percent of total billed charges,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,49.839,416.02,percent of total billed charges,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,AETNA [1000108],AETNA [100010801],,,76.8,,295.68,86.4325,416.02,percent of total billed charges,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,AETNA [1000108],AETNA [100010801],,,76.8,,295.68,86.4325,416.02,percent of total billed charges,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,AETNA [1000108],AETNA [100010801],,,76.8,,581.38,76.026473,581.376,percent of total billed charges,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,AETNA [1000108],AETNA [100010801],,,76.8,,1241.09,237.819698,1241.088,percent of total billed charges,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,AETNA [1000108],AETNA [100010801],,,76.8,,163.58,47.8185,416.02,percent of total billed charges,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,AETNA [1000108],AETNA [100010801],,,76.8,,163.58,47.8185,416.02,percent of total billed charges,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,AETNA [1000108],AETNA [100010801],,,76.8,,178.18,52.084,416.02,percent of total billed charges,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,AETNA [1000108],AETNA [100010801],,,76.8,,199.68,58.37,416.02,percent of total billed charges,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,76.8,,302.59,71.24,416.02,percent of total billed charges,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,AETNA [1000108],AETNA [100010801],,,76.8,,1308.67,382.548,1308.672,percent of total billed charges,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,AETNA [1000108],AETNA [100010801],,,76.8,,152.83,44.6755,416.02,percent of total billed charges,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,AETNA [1000108],AETNA [100010801],,,76.8,,177.41,51.8595,416.02,percent of total billed charges,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,AETNA [1000108],AETNA [100010801],,,76.8,,105.22,30.7565,416.02,percent of total billed charges,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,AETNA [1000108],AETNA [100010801],,,76.8,,99.84,29.185,416.02,percent of total billed charges,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,AETNA [1000108],AETNA [100010801],,,76.8,,937.73,237.819698,1020.2995,percent of total billed charges,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,AETNA [1000108],AETNA [100010801],,,76.8,,121.34,35.471,416.02,percent of total billed charges,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,AETNA [1000108],AETNA [100010801],,,76.8,,125.95,36.818,416.02,percent of total billed charges,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,AETNA [1000108],AETNA [100010801],,,76.8,,179.71,52.533,416.02,percent of total billed charges,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,AETNA [1000108],AETNA [100010801],,,76.8,,147.46,43.104,416.02,percent of total billed charges,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,AETNA [1000108],AETNA [100010801],,,76.8,,743.42,96.160741,743.424,percent of total billed charges,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,AETNA [1000108],AETNA [100010801],,,76.8,,758.02,196.51,758.016,percent of total billed charges,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,AETNA [1000108],AETNA [100010801],,,76.8,,1461.5,200.53123,1461.504,percent of total billed charges,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,AETNA [1000108],AETNA [100010801],,,76.8,,903.17,200.53123,903.168,percent of total billed charges,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,AETNA [1000108],AETNA [100010801],,,76.8,,2178.05,237.688956,2178.048,percent of total billed charges,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,AETNA [1000108],AETNA [100010801],,,76.8,,1840.13,372.66,1840.128,percent of total billed charges,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,AETNA [1000108],AETNA [100010801],,,76.8,,2350.08,399.547552,2350.08,percent of total billed charges,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,AETNA [1000108],AETNA [100010801],,,76.8,,2310.14,205.15,2310.144,percent of total billed charges,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,AETNA [1000108],AETNA [100010801],,,76.8,,2317.82,345.98,2317.824,percent of total billed charges,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,AETNA [1000108],AETNA [100010801],,,76.8,,2379.26,399.547552,2379.264,percent of total billed charges,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,AETNA [1000108],AETNA [100010801],,,76.8,,2081.28,399.86,2290.176,percent of total billed charges,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,AETNA [1000108],AETNA [100010801],,,76.8,,2081.28,399.86,2290.176,percent of total billed charges,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,AETNA [1000108],AETNA [100010801],,,76.8,,2290.18,399.86,2290.176,percent of total billed charges,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,AETNA [1000108],AETNA [100010801],,,76.8,,178.18,52.084,416.02,percent of total billed charges,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,AETNA [1000108],AETNA [100010801],,,76.8,,340.22,76.026473,416.02,percent of total billed charges,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,AETNA [1000108],AETNA [100010801],,,76.8,,314.88,92.045,416.02,percent of total billed charges,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,AETNA [1000108],AETNA [100010801],,,76.8,,1112.83,96.160741,1112.832,percent of total billed charges,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,AETNA [1000108],AETNA [100010801],,,76.8,,1218.05,194.55,1218.048,percent of total billed charges,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,AETNA [1000108],AETNA [100010801],,,76.8,,1580.54,200.53123,1580.544,percent of total billed charges,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,AETNA [1000108],AETNA [100010801],,,76.8,,1982.21,329.339098,1982.208,percent of total billed charges,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,AETNA [1000108],AETNA [100010801],,,76.8,,1040.64,200.53123,1040.64,percent of total billed charges,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,AETNA [1000108],AETNA [100010801],,,76.8,,1050.62,142.38,1050.624,percent of total billed charges,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,AETNA [1000108],AETNA [100010801],,,76.8,,1513.73,204.61123,1513.728,percent of total billed charges,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,AETNA [1000108],AETNA [100010801],,,76.8,,1629.7,204.61123,1629.696,percent of total billed charges,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,AETNA [1000108],AETNA [100010801],,,76.8,,1810.18,237.688956,1810.176,percent of total billed charges,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,AETNA [1000108],AETNA [100010801],,,76.8,,3902.21,399.547552,3902.208,percent of total billed charges,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,AETNA [1000108],AETNA [100010801],,,76.8,,2072.06,399.547552,2072.064,percent of total billed charges,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA [1000108],AETNA [100010801],,,76.8,,1878.53,301.425681,1878.528,percent of total billed charges,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA [1000108],AETNA [100010801],,,76.8,,1878.53,301.425681,1878.528,percent of total billed charges,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA [1000108],AETNA [100010801],,,76.8,,1878.53,301.425681,1878.528,percent of total billed charges,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,AETNA [1000108],AETNA [100010801],,,76.8,,753.41,76.026473,753.408,percent of total billed charges,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,AETNA [1000108],AETNA [100010801],,,76.8,,671.23,128.66,671.232,percent of total billed charges,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,AETNA [1000108],AETNA [100010801],,,76.8,,888.58,259.7465,888.576,percent of total billed charges,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,AETNA [1000108],AETNA [100010801],,,76.8,,703.49,200.53123,703.488,percent of total billed charges,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,AETNA [1000108],AETNA [100010801],,,76.8,,664.32,194.1925,664.32,percent of total billed charges,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,AETNA [1000108],AETNA [100010801],,,76.8,,2264.83,128.66,2264.832,percent of total billed charges,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,AETNA [1000108],AETNA [100010801],,,76.8,,907.78,183.14,907.776,percent of total billed charges,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,AETNA [1000108],AETNA [100010801],,,76.8,,822.53,200.53123,822.528,percent of total billed charges,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,AETNA [1000108],AETNA [100010801],,,76.8,,1350.14,200.53123,1350.144,percent of total billed charges,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,AETNA [1000108],AETNA [100010801],,,76.8,,1026.05,145.12362,1026.048,percent of total billed charges,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,AETNA [1000108],AETNA [100010801],,,76.8,,221.95,64.8805,416.02,percent of total billed charges,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,AETNA [1000108],AETNA [100010801],,,76.8,,797.18,145.12362,797.184,percent of total billed charges,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,AETNA [1000108],AETNA [100010801],,,76.8,,669.7,195.08,669.696,percent of total billed charges,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,AETNA [1000108],AETNA [100010801],,,76.8,,2237.18,260.23,2237.184,percent of total billed charges,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,AETNA [1000108],AETNA [100010801],,,76.8,,484.61,141.6595,484.608,percent of total billed charges,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,AETNA [1000108],AETNA [100010801],,,76.8,,1890.82,399.86,1890.816,percent of total billed charges,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,AETNA [1000108],AETNA [100010801],,,76.8,,460.03,134.4755,499.422,percent of total billed charges,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,AETNA [1000108],AETNA [100010801],,,76.8,,1595.9,200.53123,1595.904,percent of total billed charges,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,AETNA [1000108],AETNA [100010801],,,76.8,,913.15,237.819698,1020.2995,percent of total billed charges,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,AETNA [1000108],AETNA [100010801],,,76.8,,2172.67,399.86,2172.672,percent of total billed charges,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,AETNA [1000108],AETNA [100010801],,,76.8,,913.15,237.819698,1020.2995,percent of total billed charges,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,AETNA [1000108],AETNA [100010801],,,76.8,,585.22,171.069,646.6965,percent of total billed charges,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,AETNA [1000108],AETNA [100010801],,,76.8,,585.22,171.069,646.6965,percent of total billed charges,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,AETNA [1000108],AETNA [100010801],,,76.8,,416.26,121.679,1393.3385,percent of total billed charges,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,AETNA [1000108],AETNA [100010801],,,76.8,,2624.26,399.86,5136.771,percent of total billed charges,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,AETNA [1000108],AETNA [100010801],,,76.8,,1301.76,237.819698,1301.76,percent of total billed charges,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,AETNA [1000108],AETNA [100010801],,,76.8,,975.36,285.115,975.36,percent of total billed charges,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,AETNA [1000108],AETNA [100010801],,,76.8,,1706.5,88.902,1706.496,percent of total billed charges,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,AETNA [1000108],AETNA [100010801],,,76.8,,304.13,88.902,1706.496,percent of total billed charges,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,AETNA [1000108],AETNA [100010801],,,76.8,,2030.59,102.5965,2030.592,percent of total billed charges,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,AETNA [1000108],AETNA [100010801],,,76.8,,350.98,102.5965,2030.592,percent of total billed charges,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,9.2045,836,percent of total billed charges,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,AETNA [1000108],AETNA [100010801],,,76.8,,31.49,9.2045,836,percent of total billed charges,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,AETNA [1000108],AETNA [100010801],,,76.8,,202.75,19.0825,575,percent of total billed charges,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,AETNA [1000108],AETNA [100010801],,,76.8,,65.28,19.0825,575,percent of total billed charges,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,AETNA [1000108],AETNA [100010801],,,76.8,,669.7,58.819,669.696,percent of total billed charges,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,669.696,percent of total billed charges,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,AETNA [1000108],AETNA [100010801],,,76.8,,780.29,58.819,780.288,percent of total billed charges,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,780.288,percent of total billed charges,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,AETNA [1000108],AETNA [100010801],,,76.8,,824.06,57.921,824.064,percent of total billed charges,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,AETNA [1000108],AETNA [100010801],,,76.8,,198.14,57.921,824.064,percent of total billed charges,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,AETNA [1000108],AETNA [100010801],,,76.8,,2193.41,399.86,2536.61118,percent of total billed charges,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,AETNA [1000108],AETNA [100010801],,,76.8,,2423.04,399.86,8249.769,percent of total billed charges,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,14233.715,percent of total billed charges,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,AETNA [1000108],AETNA [100010801],,,76.8,,4342.27,399.86,8249.769,percent of total billed charges,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,8249.769,percent of total billed charges,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,AETNA [1000108],AETNA [100010801],,,76.8,,1321.73,200.53123,1321.728,percent of total billed charges,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA [1000108],AETNA [100010801],,,76.8,,8757.5,399.86,14233.715,percent of total billed charges,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,AETNA [1000108],AETNA [100010801],,,76.8,,4983.55,399.86,8249.769,percent of total billed charges,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,AETNA [1000108],AETNA [100010801],,,76.8,,5500.42,399.86,8249.769,percent of total billed charges,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,AETNA [1000108],AETNA [100010801],,,76.8,,7550.21,399.86,14233.715,percent of total billed charges,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,8249.769,percent of total billed charges,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA [1000108],AETNA [100010801],,,76.8,,8757.5,399.86,14233.715,percent of total billed charges,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,AETNA [1000108],AETNA [100010801],,,76.8,,5500.42,399.86,8249.769,percent of total billed charges,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,8249.769,percent of total billed charges,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,AETNA [1000108],AETNA [100010801],,,76.8,,2717.18,399.86,2717.184,percent of total billed charges,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,AETNA [1000108],AETNA [100010801],,,76.8,,315.65,92.2695,416.02,percent of total billed charges,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA [1000108],AETNA [100010801],,,76.8,,5912.06,399.86,8249.769,percent of total billed charges,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,AETNA [1000108],AETNA [100010801],,,76.8,,2466.82,399.86,4120.349,percent of total billed charges,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,AETNA [1000108],AETNA [100010801],,,76.8,,2257.92,399.86,4120.349,percent of total billed charges,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,AETNA [1000108],AETNA [100010801],,,76.8,,4598.02,399.86,8249.769,percent of total billed charges,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,AETNA [1000108],AETNA [100010801],,,76.8,,2207.23,399.86,4120.349,percent of total billed charges,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,AETNA [1000108],AETNA [100010801],,,76.8,,4983.55,399.86,8249.769,percent of total billed charges,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA [1000108],AETNA [100010801],,,76.8,,5912.06,399.86,8249.769,percent of total billed charges,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA [1000108],AETNA [100010801],,,76.8,,8757.5,399.86,14233.715,percent of total billed charges,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,AETNA [1000108],AETNA [100010801],,,76.8,,3400.7,399.86,8249.769,percent of total billed charges,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,AETNA [1000108],AETNA [100010801],,,76.8,,3400.7,399.86,3400.704,percent of total billed charges,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,AETNA [1000108],AETNA [100010801],,,76.8,,1257.98,367.731,1602.0655,percent of total billed charges,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA [1000108],AETNA [100010801],,,76.8,,5912.06,399.86,8249.769,percent of total billed charges,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,8249.769,percent of total billed charges,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,AETNA [1000108],AETNA [100010801],,,76.8,,4048.9,399.86,8249.769,percent of total billed charges,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA [1000108],AETNA [100010801],,,76.8,,8757.5,399.86,14233.715,percent of total billed charges,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,AETNA [1000108],AETNA [100010801],,,76.8,,1947.65,145.12362,1947.648,percent of total billed charges,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,AETNA [1000108],AETNA [100010801],,,76.8,,2877.7,260.23,8249.769,percent of total billed charges,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,AETNA [1000108],AETNA [100010801],,,76.8,,3665.66,260.23,3665.664,percent of total billed charges,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,76.8,,361.73,105.7395,416.02,percent of total billed charges,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,AETNA [1000108],AETNA [100010801],,,76.8,,1110.53,324.627,1110.528,percent of total billed charges,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,AETNA [1000108],AETNA [100010801],,,76.8,,1007.62,294.544,1007.616,percent of total billed charges,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,648.96,percent of total billed charges,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,AETNA [1000108],AETNA [100010801],,,76.8,,571.39,167.028,571.392,percent of total billed charges,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,AETNA [1000108],AETNA [100010801],,,76.8,,2241.02,145.12362,2241.024,percent of total billed charges,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,AETNA [1000108],AETNA [100010801],,,76.8,,2215.68,145.12362,2215.68,percent of total billed charges,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,AETNA [1000108],AETNA [100010801],,,76.8,,681.98,145.12362,681.984,percent of total billed charges,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,AETNA [1000108],AETNA [100010801],,,76.8,,681.98,145.12362,681.984,percent of total billed charges,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,AETNA [1000108],AETNA [100010801],,,76.8,,765.7,195.08,765.696,percent of total billed charges,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,AETNA [1000108],AETNA [100010801],,,76.8,,261.12,71.24,416.02,percent of total billed charges,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,AETNA [1000108],AETNA [100010801],,,76.8,,1497.6,237.819698,1497.6,percent of total billed charges,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,AETNA [1000108],AETNA [100010801],,,76.8,,755.71,220.908,1393.3385,percent of total billed charges,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,AETNA [1000108],AETNA [100010801],,,76.8,,293.38,85.759,416.02,percent of total billed charges,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,79.024,836,percent of total billed charges,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,79.024,836,percent of total billed charges,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,79.024,836,percent of total billed charges,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,AETNA [1000108],AETNA [100010801],,,76.8,,324.1,94.739,836,percent of total billed charges,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,AETNA [1000108],AETNA [100010801],,,76.8,,324.1,94.739,836,percent of total billed charges,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,AETNA [1000108],AETNA [100010801],,,76.8,,324.1,94.739,836,percent of total billed charges,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,AETNA [1000108],AETNA [100010801],,,76.8,,712.7,71.24,712.704,percent of total billed charges,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,AETNA [1000108],AETNA [100010801],,,76.8,,1703.42,81.08,1703.424,percent of total billed charges,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,189.029,836,percent of total billed charges,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,AETNA [1000108],AETNA [100010801],,,76.8,,175.87,51.4105,575,percent of total billed charges,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,AETNA [1000108],AETNA [100010801],,,76.8,,332.54,97.2085,416.02,percent of total billed charges,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,AETNA [1000108],AETNA [100010801],,,76.8,,340.99,99.678,416.02,percent of total billed charges,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,76.8,,320.26,93.6165,416.02,percent of total billed charges,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,AETNA [1000108],AETNA [100010801],,,76.8,,295.68,86.4325,416.02,percent of total billed charges,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,76.8,,271.1,71.24,416.02,percent of total billed charges,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,AETNA [1000108],AETNA [100010801],,,76.8,,354.05,103.4945,416.02,percent of total billed charges,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,AETNA [1000108],AETNA [100010801],,,76.8,,261.89,76.5545,416.02,percent of total billed charges,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,AETNA [1000108],AETNA [100010801],,,76.8,,200.45,58.5945,416.02,percent of total billed charges,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,AETNA [1000108],AETNA [100010801],,,76.8,,282.62,82.616,416.02,percent of total billed charges,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,AETNA [1000108],AETNA [100010801],,,76.8,,264.96,77.4525,416.02,percent of total billed charges,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,AETNA [1000108],AETNA [100010801],,,76.8,,456.96,119.991125,456.96,percent of total billed charges,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,AETNA [1000108],AETNA [100010801],,,76.8,,221.95,64.8805,416.02,percent of total billed charges,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,AETNA [1000108],AETNA [100010801],,,76.8,,172.03,50.288,416.02,percent of total billed charges,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,AETNA [1000108],AETNA [100010801],,,76.8,,323.33,94.5145,416.02,percent of total billed charges,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,AETNA [1000108],AETNA [100010801],,,76.8,,547.58,157.086513,547.584,percent of total billed charges,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,AETNA [1000108],AETNA [100010801],,,76.8,,556.8,162.7625,646.6965,percent of total billed charges,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,AETNA [1000108],AETNA [100010801],,,76.8,,232.7,68.0235,416.02,percent of total billed charges,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,AETNA [1000108],AETNA [100010801],,,76.8,,460.8,119.991125,460.8,percent of total billed charges,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,AETNA [1000108],AETNA [100010801],,,76.8,,272.64,79.6975,416.02,percent of total billed charges,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,AETNA [1000108],AETNA [100010801],,,76.8,,337.15,98.5555,416.02,percent of total billed charges,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,80.371,416.02,percent of total billed charges,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,AETNA [1000108],AETNA [100010801],,,76.8,,222.72,65.105,416.02,percent of total billed charges,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,AETNA [1000108],AETNA [100010801],,,76.8,,443.9,119.991125,443.904,percent of total billed charges,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,AETNA [1000108],AETNA [100010801],,,76.8,,112.13,32.777,416.02,percent of total billed charges,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,AETNA [1000108],AETNA [100010801],,,76.8,,280.32,81.9425,416.02,percent of total billed charges,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,AETNA [1000108],AETNA [100010801],,,76.8,,772.61,199.512292,772.608,percent of total billed charges,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,AETNA [1000108],AETNA [100010801],,,76.8,,277.25,81.0445,416.02,percent of total billed charges,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,AETNA [1000108],AETNA [100010801],,,76.8,,254.98,74.534,416.02,percent of total billed charges,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,AETNA [1000108],AETNA [100010801],,,76.8,,350.98,102.5965,416.02,percent of total billed charges,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,AETNA [1000108],AETNA [100010801],,,76.8,,307.97,90.0245,416.02,percent of total billed charges,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,AETNA [1000108],AETNA [100010801],,,76.8,,209.66,61.2885,416.02,percent of total billed charges,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,AETNA [1000108],AETNA [100010801],,,76.8,,307.2,89.8,416.02,percent of total billed charges,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,AETNA [1000108],AETNA [100010801],,,76.8,,194.3,56.7985,416.02,percent of total billed charges,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,76.8,,316.42,71.24,416.02,percent of total billed charges,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,76.8,,316.42,71.24,416.02,percent of total billed charges,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,AETNA [1000108],AETNA [100010801],,,76.8,,523.01,152.8845,775.5705,percent of total billed charges,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,AETNA [1000108],AETNA [100010801],,,76.8,,192.77,56.3495,416.02,percent of total billed charges,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,AETNA [1000108],AETNA [100010801],,,76.8,,353.28,103.27,416.02,percent of total billed charges,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,AETNA [1000108],AETNA [100010801],,,76.8,,666.62,166.37,666.624,percent of total billed charges,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,416.02,percent of total billed charges,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,AETNA [1000108],AETNA [100010801],,,76.8,,463.87,135.598,463.872,percent of total billed charges,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,AETNA [1000108],AETNA [100010801],,,76.8,,400.13,116.9645,416.02,percent of total billed charges,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,AETNA [1000108],AETNA [100010801],,,76.8,,244.22,71.391,416.02,percent of total billed charges,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,AETNA [1000108],AETNA [100010801],,,76.8,,397.82,116.291,416.02,percent of total billed charges,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,AETNA [1000108],AETNA [100010801],,,76.8,,1383.17,399.86,1383.168,percent of total billed charges,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,AETNA [1000108],AETNA [100010801],,,76.8,,1341.7,63.344499,1341.696,percent of total billed charges,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,AETNA [1000108],AETNA [100010801],,,76.8,,1347.84,63.344499,1347.84,percent of total billed charges,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,AETNA [1000108],AETNA [100010801],,,76.8,,478.46,139.8635,575,percent of total billed charges,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,AETNA [1000108],AETNA [100010801],,,76.8,,2374.66,399.86,2374.656,percent of total billed charges,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,189.029,836,percent of total billed charges,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,189.029,836,percent of total billed charges,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,AETNA [1000108],AETNA [100010801],,,76.8,,1626.62,399.547552,1936.896,percent of total billed charges,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,AETNA [1000108],AETNA [100010801],,,76.8,,1936.9,399.547552,1936.896,percent of total billed charges,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,AETNA [1000108],AETNA [100010801],,,76.8,,2141.18,399.547552,2548.224,percent of total billed charges,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,AETNA [1000108],AETNA [100010801],,,76.8,,2548.22,399.547552,2548.224,percent of total billed charges,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,AETNA [1000108],AETNA [100010801],,,76.8,,246.53,72.0645,416.02,percent of total billed charges,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,AETNA [1000108],AETNA [100010801],,,76.8,,301.82,88.2285,416.02,percent of total billed charges,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,AETNA [1000108],AETNA [100010801],,,76.8,,155.14,22.99364,416.02,percent of total billed charges,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,AETNA [1000108],AETNA [100010801],,,76.8,,301.82,88.2285,416.02,percent of total billed charges,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,90.800319,416.02,percent of total billed charges,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,90.800319,416.02,percent of total billed charges,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,416.02,percent of total billed charges,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,AETNA [1000108],AETNA [100010801],,,76.8,,167.42,48.941,416.02,percent of total billed charges,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,76.026473,416.02,percent of total billed charges,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,112.699,416.02,percent of total billed charges,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,112.699,416.02,percent of total billed charges,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,76.026473,416.02,percent of total billed charges,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,AETNA [1000108],AETNA [100010801],,,76.8,,441.6,119.991125,441.6,percent of total billed charges,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,AETNA [1000108],AETNA [100010801],,,76.8,,87.55,25.593,416.02,percent of total billed charges,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,AETNA [1000108],AETNA [100010801],,,76.8,,1847.81,267.439885,1847.808,percent of total billed charges,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,AETNA [1000108],AETNA [100010801],,,76.8,,190.46,55.676,416.02,percent of total billed charges,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,AETNA [1000108],AETNA [100010801],,,76.8,,190.46,55.676,416.02,percent of total billed charges,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,AETNA [1000108],AETNA [100010801],,,76.8,,718.08,209.9075,1076.394,percent of total billed charges,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,AETNA [1000108],AETNA [100010801],,,76.8,,486.14,142.1085,1076.394,percent of total billed charges,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,AETNA [1000108],AETNA [100010801],,,76.8,,754.18,220.459,1076.394,percent of total billed charges,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,AETNA [1000108],AETNA [100010801],,,76.8,,805.63,235.5005,1397.122,percent of total billed charges,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,AETNA [1000108],AETNA [100010801],,,76.8,,131.33,38.3895,416.02,percent of total billed charges,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,AETNA [1000108],AETNA [100010801],,,76.8,,1209.6,353.5875,1209.6,percent of total billed charges,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,AETNA [1000108],AETNA [100010801],,,76.8,,1042.18,304.6465,1076.394,percent of total billed charges,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,AETNA [1000108],AETNA [100010801],,,76.8,,1457.66,358.69,1457.664,percent of total billed charges,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,399.86,3675.6585,percent of total billed charges,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,AETNA [1000108],AETNA [100010801],,,76.8,,1077.5,314.9735,1077.504,percent of total billed charges,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,AETNA [1000108],AETNA [100010801],,,76.8,,1077.5,314.9735,1077.504,percent of total billed charges,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,AETNA [1000108],AETNA [100010801],,,76.8,,506.11,147.9455,1076.394,percent of total billed charges,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,AETNA [1000108],AETNA [100010801],,,76.8,,745.73,217.9895,1076.394,percent of total billed charges,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,AETNA [1000108],AETNA [100010801],,,76.8,,822.53,240.4395,1397.122,percent of total billed charges,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,AETNA [1000108],AETNA [100010801],,,76.8,,1711.1,399.86,2239.93036,percent of total billed charges,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,AETNA [1000108],AETNA [100010801],,,76.8,,925.44,270.5225,1076.394,percent of total billed charges,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,AETNA [1000108],AETNA [100010801],,,76.8,,1062.91,310.708,1076.394,percent of total billed charges,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,AETNA [1000108],AETNA [100010801],,,76.8,,1062.91,310.708,1397.122,percent of total billed charges,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,AETNA [1000108],AETNA [100010801],,,76.8,,605.18,176.906,1076.394,percent of total billed charges,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,AETNA [1000108],AETNA [100010801],,,76.8,,801.02,234.1535,1076.394,percent of total billed charges,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,AETNA [1000108],AETNA [100010801],,,76.8,,643.58,188.131,1076.394,percent of total billed charges,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,AETNA [1000108],AETNA [100010801],,,76.8,,1596.67,399.86,1596.672,percent of total billed charges,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,AETNA [1000108],AETNA [100010801],,,76.8,,685.82,200.4785,1076.394,percent of total billed charges,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,AETNA [1000108],AETNA [100010801],,,76.8,,732.67,214.173,1076.394,percent of total billed charges,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,AETNA [1000108],AETNA [100010801],,,76.8,,738.82,215.969,1076.394,percent of total billed charges,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,AETNA [1000108],AETNA [100010801],,,76.8,,843.26,246.501,1076.394,percent of total billed charges,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,AETNA [1000108],AETNA [100010801],,,76.8,,685.82,200.4785,1076.394,percent of total billed charges,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,AETNA [1000108],AETNA [100010801],,,76.8,,734.21,214.622,1076.394,percent of total billed charges,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,AETNA [1000108],AETNA [100010801],,,76.8,,3463.68,399.86,3675.6585,percent of total billed charges,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,AETNA [1000108],AETNA [100010801],,,76.8,,3463.68,399.86,3675.6585,percent of total billed charges,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,AETNA [1000108],AETNA [100010801],,,76.8,,2995.2,399.86,3675.6585,percent of total billed charges,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,AETNA [1000108],AETNA [100010801],,,76.8,,2995.2,399.86,3675.6585,percent of total billed charges,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,AETNA [1000108],AETNA [100010801],,,76.8,,1218.05,356.057,1218.048,percent of total billed charges,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,AETNA [1000108],AETNA [100010801],,,76.8,,1283.33,375.1395,1283.328,percent of total billed charges,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,AETNA [1000108],AETNA [100010801],,,76.8,,589.06,172.1915,1076.394,percent of total billed charges,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,AETNA [1000108],AETNA [100010801],,,76.8,,491.52,143.68,1076.394,percent of total billed charges,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,AETNA [1000108],AETNA [100010801],,,76.8,,726.53,212.377,1397.122,percent of total billed charges,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,AETNA [1000108],AETNA [100010801],,,76.8,,692.74,202.499,1076.394,percent of total billed charges,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,AETNA [1000108],AETNA [100010801],,,76.8,,1151.23,336.5255,1397.122,percent of total billed charges,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,AETNA [1000108],AETNA [100010801],,,76.8,,2076.67,399.86,2076.672,percent of total billed charges,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,AETNA [1000108],AETNA [100010801],,,76.8,,1220.35,356.7305,1397.122,percent of total billed charges,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,AETNA [1000108],AETNA [100010801],,,76.8,,3755.52,399.86,3755.52,percent of total billed charges,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,AETNA [1000108],AETNA [100010801],,,76.8,,1973.76,399.86,1973.76,percent of total billed charges,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,AETNA [1000108],AETNA [100010801],,,76.8,,703.49,205.642,1397.122,percent of total billed charges,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,AETNA [1000108],AETNA [100010801],,,76.8,,2469.12,399.86,3675.6585,percent of total billed charges,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,AETNA [1000108],AETNA [100010801],,,76.8,,992.26,290.054,1076.394,percent of total billed charges,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,AETNA [1000108],AETNA [100010801],,,76.8,,929.28,271.645,1397.122,percent of total billed charges,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,AETNA [1000108],AETNA [100010801],,,76.8,,690.43,201.8255,1397.122,percent of total billed charges,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,1076.394,percent of total billed charges,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,AETNA [1000108],AETNA [100010801],,,76.8,,665.86,194.6415,1076.394,percent of total billed charges,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,AETNA [1000108],AETNA [100010801],,,76.8,,2399.23,399.86,3675.6585,percent of total billed charges,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,AETNA [1000108],AETNA [100010801],,,76.8,,1857.79,399.86,3675.6585,percent of total billed charges,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,AETNA [1000108],AETNA [100010801],,,76.8,,2239.49,399.86,3675.6585,percent of total billed charges,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,AETNA [1000108],AETNA [100010801],,,76.8,,942.34,275.4615,1076.394,percent of total billed charges,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,AETNA [1000108],AETNA [100010801],,,76.8,,3982.85,399.86,3982.848,percent of total billed charges,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,AETNA [1000108],AETNA [100010801],,,76.8,,5302.27,399.86,5302.272,percent of total billed charges,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,AETNA [1000108],AETNA [100010801],,,76.8,,5917.44,399.86,5917.44,percent of total billed charges,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,AETNA [1000108],AETNA [100010801],,,76.8,,3316.22,399.86,3675.6585,percent of total billed charges,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,AETNA [1000108],AETNA [100010801],,,76.8,,3316.22,399.86,3675.6585,percent of total billed charges,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,AETNA [1000108],AETNA [100010801],,,76.8,,3762.43,399.86,4124.5085,percent of total billed charges,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,AETNA [1000108],AETNA [100010801],,,76.8,,155.9,45.5735,416.02,percent of total billed charges,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,AETNA [1000108],AETNA [100010801],,,76.8,,600.58,175.559,691.5815,percent of total billed charges,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,AETNA [1000108],AETNA [100010801],,,76.8,,24.58,2.29,24.576,percent of total billed charges,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,AETNA [1000108],AETNA [100010801],,,76.8,,21.5,6.286,21.504,percent of total billed charges,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,AETNA [1000108],AETNA [100010801],,,76.8,,549.89,160.742,549.888,percent of total billed charges,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,AETNA [1000108],AETNA [100010801],,,76.8,,18.43,3.33,18.432,percent of total billed charges,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,AETNA [1000108],AETNA [100010801],,,76.8,,34.56,2.4,34.56,percent of total billed charges,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,AETNA [1000108],AETNA [100010801],,,76.8,,797.18,39.73,1313.895373,percent of total billed charges,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,AETNA [1000108],AETNA [100010801],,,76.8,,61.44,4.35,61.44,percent of total billed charges,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,AETNA [1000108],AETNA [100010801],,,76.8,,24.58,6.78,24.576,percent of total billed charges,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,5.6125,19.2,percent of total billed charges,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,AETNA [1000108],AETNA [100010801],,,76.8,,98.3,18.77,98.304,percent of total billed charges,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,AETNA [1000108],AETNA [100010801],,,76.8,,121.34,6.51,121.344,percent of total billed charges,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,76.8,,22.27,6.5105,24.43,percent of total billed charges,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,AETNA [1000108],AETNA [100010801],,,76.8,,25.34,7.4085,25.344,percent of total billed charges,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,AETNA [1000108],AETNA [100010801],,,76.8,,119.04,14.71,119.04,percent of total billed charges,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,AETNA [1000108],AETNA [100010801],,,76.8,,193.54,26.37,193.536,percent of total billed charges,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,AETNA [1000108],AETNA [100010801],,,76.8,,95.23,27.838,95.232,percent of total billed charges,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,76.8,,220.42,64.4315,241.472,percent of total billed charges,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,AETNA [1000108],AETNA [100010801],,,76.8,,76.03,6.25,92.88556,percent of total billed charges,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,2.072,274.944,percent of total billed charges,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,AETNA [1000108],AETNA [100010801],,,76.8,,384.77,2.842,549.235176,percent of total billed charges,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,AETNA [1000108],AETNA [100010801],,,76.8,,89.86,5.5,93.463636,percent of total billed charges,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,5.85,274.176,percent of total billed charges,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,5.29,274.176,percent of total billed charges,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,AETNA [1000108],AETNA [100010801],,,76.8,,159.74,3.05,195.186327,percent of total billed charges,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,AETNA [1000108],AETNA [100010801],,,76.8,,65.28,3.05,65.28,percent of total billed charges,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,AETNA [1000108],AETNA [100010801],,,76.8,,482.3,3.91,549.235176,percent of total billed charges,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,AETNA [1000108],AETNA [100010801],,,76.8,,238.85,9.71,238.848,percent of total billed charges,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,AETNA [1000108],AETNA [100010801],,,76.8,,482.3,3.91,549.235176,percent of total billed charges,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,AETNA [1000108],AETNA [100010801],,,76.8,,218.11,7.91,218.112,percent of total billed charges,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,AETNA [1000108],AETNA [100010801],,,76.8,,272.64,2.31,272.64,percent of total billed charges,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,2.072,274.176,percent of total billed charges,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,2.45,274.176,percent of total billed charges,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,1.862,274.176,percent of total billed charges,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,76.8,,239.62,1.302,263.69806,percent of total billed charges,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,AETNA [1000108],AETNA [100010801],,,,,,1.932,416.02,other,Rev 391 at $0
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,AETNA [1000108],AETNA [100010801],,,76.8,,84.48,1.932,93.463636,percent of total billed charges,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,AETNA [1000108],AETNA [100010801],,,76.8,,430.08,1.54,499.62884,percent of total billed charges,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,2.702,274.944,percent of total billed charges,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,2.072,608.812631,percent of total billed charges,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,AETNA [1000108],AETNA [100010801],,,76.8,,238.85,2.31,238.848,percent of total billed charges,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,AETNA [1000108],AETNA [100010801],,,76.8,,390.91,2.31,416.02,percent of total billed charges,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,AETNA [1000108],AETNA [100010801],,,,,,2.31,416.02,other,Rev 391 at $0
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,AETNA [1000108],AETNA [100010801],,,76.8,,238.85,2.31,238.848,percent of total billed charges,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,AETNA [1000108],AETNA [100010801],,,76.8,,229.63,1.68,229.632,percent of total billed charges,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,AETNA [1000108],AETNA [100010801],,,76.8,,39.94,11.674,39.936,percent of total billed charges,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,AETNA [1000108],AETNA [100010801],,,76.8,,161.28,47.145,416.02,percent of total billed charges,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,AETNA [1000108],AETNA [100010801],,,76.8,,116.74,34.124,116.736,percent of total billed charges,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,AETNA [1000108],AETNA [100010801],,,76.8,,44.54,12.32,44.544,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,AETNA [1000108],AETNA [100010801],,,76.8,,499.55,139.93,1690.176,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,AETNA [1000108],AETNA [100010801],,,76.8,,1690.18,139.93,1690.176,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,AETNA [1000108],AETNA [100010801],,,76.8,,499.55,139.93,1690.176,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,AETNA [1000108],AETNA [100010801],,,76.8,,1690.18,139.93,1690.176,percent of total billed charges,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,AETNA [1000108],AETNA [100010801],,,76.8,,1193.64,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,AETNA [1000108],AETNA [100010801],,,76.8,,1193.64,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,AETNA [1000108],AETNA [100010801],,,76.8,,5968.2,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,AETNA [1000108],AETNA [100010801],,,76.8,,5968.2,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,AETNA [1000108],AETNA [100010801],,,76.8,,3580.92,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,AETNA [1000108],AETNA [100010801],,,76.8,,3580.92,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,AETNA [1000108],AETNA [100010801],,,76.8,,1421.12,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,AETNA [1000108],AETNA [100010801],,,76.8,,1421.12,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,AETNA [1000108],AETNA [100010801],,,76.8,,7105.57,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,AETNA [1000108],AETNA [100010801],,,76.8,,7105.57,287.71,7105.5744,percent of total billed charges,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,AETNA [1000108],AETNA [100010801],,,76.8,,3859.22,389.10344,4791.979,percent of total billed charges,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,AETNA [1000108],AETNA [100010801],,,76.8,,159.05,0.5,416.02,percent of total billed charges,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,AETNA [1000108],AETNA [100010801],,,76.8,,159.05,0.5,416.02,percent of total billed charges,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,AETNA [1000108],AETNA [100010801],,,76.8,,60.27,0.5,416.02,percent of total billed charges,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,43.3285,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,AETNA [1000108],AETNA [100010801],,,76.8,,56.06,16.3885,416.02,percent of total billed charges,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,AETNA [1000108],AETNA [100010801],,,76.8,,85.25,24.9195,416.02,percent of total billed charges,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,AETNA [1000108],AETNA [100010801],,,76.8,,671.55,0.5,671.54688,percent of total billed charges,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,AETNA [1000108],AETNA [100010801],,,76.8,,671.55,0.5,671.54688,percent of total billed charges,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,AETNA [1000108],AETNA [100010801],,,76.8,,259.28,70.48,416.02,percent of total billed charges,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,AETNA [1000108],AETNA [100010801],,,76.8,,259.28,70.48,416.02,percent of total billed charges,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,AETNA [1000108],AETNA [100010801],,,76.8,,119.05,34.799745,416.02,percent of total billed charges,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,AETNA [1000108],AETNA [100010801],,,76.8,,119.05,34.799745,416.02,percent of total billed charges,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,AETNA [1000108],AETNA [100010801],,,76.8,,37.89,11.07683,416.02,percent of total billed charges,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,AETNA [1000108],AETNA [100010801],,,76.8,,37.89,11.07683,416.02,percent of total billed charges,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,AETNA [1000108],AETNA [100010801],,,76.8,,881.03,0.5,881.02656,percent of total billed charges,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,AETNA [1000108],AETNA [100010801],,,76.8,,881.03,0.5,881.02656,percent of total billed charges,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,AETNA [1000108],AETNA [100010801],,,76.8,,72.39,0.5,416.02,percent of total billed charges,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,AETNA [1000108],AETNA [100010801],,,76.8,,72.39,0.5,416.02,percent of total billed charges,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,AETNA [1000108],AETNA [100010801],,,76.8,,1316.02,91.911626,1316.02176,percent of total billed charges,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,AETNA [1000108],AETNA [100010801],,,76.8,,1121.66,91.911626,1316.02176,percent of total billed charges,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,AETNA [1000108],AETNA [100010801],,,76.8,,1121.66,91.911626,1316.02176,percent of total billed charges,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,AETNA [1000108],AETNA [100010801],,,76.8,,843.57,0.5,843.5712,percent of total billed charges,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,AETNA [1000108],AETNA [100010801],,,76.8,,185.61,0.5,416.02,percent of total billed charges,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,AETNA [1000108],AETNA [100010801],,,76.8,,185.61,0.5,416.02,percent of total billed charges,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,AETNA [1000108],AETNA [100010801],,,76.8,,82.57,24.135995,416.02,percent of total billed charges,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,AETNA [1000108],AETNA [100010801],,,76.8,,82.57,24.135995,416.02,percent of total billed charges,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,AETNA [1000108],AETNA [100010801],,,76.8,,278.42,54.47,416.02,percent of total billed charges,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,AETNA [1000108],AETNA [100010801],,,76.8,,278.42,54.47,416.02,percent of total billed charges,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,AETNA [1000108],AETNA [100010801],,,76.8,,125.69,25.298577,416.02,percent of total billed charges,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,AETNA [1000108],AETNA [100010801],,,76.8,,125.69,25.298577,416.02,percent of total billed charges,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,AETNA [1000108],AETNA [100010801],,,76.8,,144.33,25.298577,416.02,percent of total billed charges,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,AETNA [1000108],AETNA [100010801],,,76.8,,144.33,25.298577,416.02,percent of total billed charges,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,AETNA [1000108],AETNA [100010801],,,76.8,,148.82,25.298577,416.02,percent of total billed charges,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,AETNA [1000108],AETNA [100010801],,,76.8,,148.82,25.298577,416.02,percent of total billed charges,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,AETNA [1000108],AETNA [100010801],,,76.8,,566.11,0.5,566.10816,percent of total billed charges,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,AETNA [1000108],AETNA [100010801],,,76.8,,566.11,0.5,566.10816,percent of total billed charges,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,AETNA [1000108],AETNA [100010801],,,76.8,,301.42,0.5,416.02,percent of total billed charges,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,AETNA [1000108],AETNA [100010801],,,76.8,,301.42,0.5,416.02,percent of total billed charges,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,AETNA [1000108],AETNA [100010801],,,76.8,,492.14,0.5,492.14208,percent of total billed charges,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,AETNA [1000108],AETNA [100010801],,,76.8,,492.14,0.5,492.14208,percent of total billed charges,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,AETNA [1000108],AETNA [100010801],,,76.8,,412.82,0.5,416.02,percent of total billed charges,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,AETNA [1000108],AETNA [100010801],,,76.8,,412.82,0.5,416.02,percent of total billed charges,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,AETNA [1000108],AETNA [100010801],,,76.8,,864.77,252.787,1055.807021,percent of total billed charges,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,AETNA [1000108],AETNA [100010801],,,76.8,,1363.2,398.4875,1363.2,percent of total billed charges,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,AETNA [1000108],AETNA [100010801],,,76.8,,3012.1,399.86,3012.096,percent of total billed charges,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,AETNA [1000108],AETNA [100010801],,,76.8,,3012.1,399.86,3012.096,percent of total billed charges,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,AETNA [1000108],AETNA [100010801],,,76.8,,577.54,168.824,1592,percent of total billed charges,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,AETNA [1000108],AETNA [100010801],,,76.8,,1044.48,305.32,1592,percent of total billed charges,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,AETNA [1000108],AETNA [100010801],,,76.8,,378.41,0.5,417.629472,percent of total billed charges,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,AETNA [1000108],AETNA [100010801],,,76.8,,378.41,0.5,417.629472,percent of total billed charges,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,AETNA [1000108],AETNA [100010801],,,76.8,,61.44,17.96,416.02,percent of total billed charges,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,AETNA [1000108],AETNA [100010801],,,76.8,,975.36,163,975.36,percent of total billed charges,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,AETNA [1000108],AETNA [100010801],,,76.8,,677.38,163,677.376,percent of total billed charges,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,AETNA [1000108],AETNA [100010801],,,76.8,,422.4,123.475,422.4,percent of total billed charges,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,AETNA [1000108],AETNA [100010801],,,76.8,,119.04,34.7975,416.02,percent of total billed charges,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,AETNA [1000108],AETNA [100010801],,,76.8,,119.04,34.7975,416.02,percent of total billed charges,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,AETNA [1000108],AETNA [100010801],,,76.8,,119.04,34.7975,416.02,percent of total billed charges,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,AETNA [1000108],AETNA [100010801],,,76.8,,534.53,142.97,534.528,percent of total billed charges,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,AETNA [1000108],AETNA [100010801],,,76.8,,172.8,50.5125,416.02,percent of total billed charges,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,AETNA [1000108],AETNA [100010801],,,76.8,,206.59,60.3905,416.02,percent of total billed charges,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,AETNA [1000108],AETNA [100010801],,,76.8,,176.64,51.635,416.02,percent of total billed charges,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,AETNA [1000108],AETNA [100010801],,,76.8,,226.56,61.17,416.02,percent of total billed charges,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,AETNA [1000108],AETNA [100010801],,,76.8,,110.59,32.328,416.02,percent of total billed charges,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,AETNA [1000108],AETNA [100010801],,,76.8,,101.38,29.634,416.02,percent of total billed charges,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,AETNA [1000108],AETNA [100010801],,,76.8,,398.59,116.5155,416.02,percent of total billed charges,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,AETNA [1000108],AETNA [100010801],,,76.8,,26.88,7.8575,416.02,percent of total billed charges,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,AETNA [1000108],AETNA [100010801],,,76.8,,72.96,21.3275,416.02,percent of total billed charges,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,AETNA [1000108],AETNA [100010801],,,76.8,,96,28.0625,416.02,percent of total billed charges,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,AETNA [1000108],AETNA [100010801],,,76.8,,275.71,80.5955,416.02,percent of total billed charges,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,AETNA [1000108],AETNA [100010801],,,76.8,,384,112.25,416.02,percent of total billed charges,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,AETNA [1000108],AETNA [100010801],,,76.8,,392.45,114.7195,416.02,percent of total billed charges,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,AETNA [1000108],AETNA [100010801],,,76.8,,87.55,25.593,416.02,percent of total billed charges,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,AETNA [1000108],AETNA [100010801],,,76.8,,479.23,128.12716,479.602522,percent of total billed charges,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,AETNA [1000108],AETNA [100010801],,,76.8,,89.09,26.042,416.02,percent of total billed charges,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,AETNA [1000108],AETNA [100010801],,,76.8,,124.42,36.369,416.02,percent of total billed charges,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,AETNA [1000108],AETNA [100010801],,,76.8,,559.87,84.99,559.872,percent of total billed charges,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,AETNA [1000108],AETNA [100010801],,,76.8,,93.7,20.01,416.02,percent of total billed charges,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,AETNA [1000108],AETNA [100010801],,,76.8,,662.78,128.12716,662.784,percent of total billed charges,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,AETNA [1000108],AETNA [100010801],,,76.8,,662.78,128.12716,662.784,percent of total billed charges,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,AETNA [1000108],AETNA [100010801],,,76.8,,13488.38,399.86,13488.384,percent of total billed charges,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,AETNA [1000108],AETNA [100010801],,,76.8,,13488.38,399.86,13488.384,percent of total billed charges,
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,AETNA [1000108],AETNA [100010801],,,76.8,,25715.71,399.86,25715.712,percent of total billed charges,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,AETNA [1000108],AETNA [100010801],,,76.8,,25231.87,399.86,25231.872,percent of total billed charges,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,AETNA [1000108],AETNA [100010801],,,76.8,,25024.51,399.86,25024.512,percent of total billed charges,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,AETNA [1000108],AETNA [100010801],,,76.8,,20484.86,399.86,20484.864,percent of total billed charges,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26793.51305,percent of total billed charges,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA [1000108],AETNA [100010801],,,76.8,,20097.79,399.86,20097.792,percent of total billed charges,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,AETNA [1000108],AETNA [100010801],,,76.8,,20484.86,399.86,20484.864,percent of total billed charges,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA [1000108],AETNA [100010801],,,76.8,,20097.79,399.86,20097.792,percent of total billed charges,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,AETNA [1000108],AETNA [100010801],,,76.8,,19712.26,399.86,19712.256,percent of total billed charges,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA [1000108],AETNA [100010801],,,76.8,,20097.79,399.86,20097.792,percent of total billed charges,
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,AETNA [1000108],AETNA [100010801],,,76.8,,794.11,232.133,997.822944,percent of total billed charges,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,AETNA [1000108],AETNA [100010801],,,76.8,,794.11,232.133,997.822944,percent of total billed charges,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,AETNA [1000108],AETNA [100010801],,,76.8,,999.94,292.299,999.936,percent of total billed charges,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,AETNA [1000108],AETNA [100010801],,,76.8,,1540.61,399.86,1540.608,percent of total billed charges,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,AETNA [1000108],AETNA [100010801],,,76.8,,1540.61,399.86,1540.608,percent of total billed charges,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,AETNA [1000108],AETNA [100010801],,,76.8,,593.66,173.5385,593.664,percent of total billed charges,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,145.12362,2138.88,percent of total billed charges,
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,145.12362,2138.88,percent of total billed charges,
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,AETNA [1000108],AETNA [100010801],,,76.8,,579.84,169.4975,1592,percent of total billed charges,
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,AETNA [1000108],AETNA [100010801],,,76.8,,579.84,169.4975,1592,percent of total billed charges,
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA [1000108],AETNA [100010801],,,76.8,,13233.41,399.86,13233.408,percent of total billed charges,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA [1000108],AETNA [100010801],,,76.8,,13233.41,399.86,16809.6787,percent of total billed charges,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA [1000108],AETNA [100010801],,,76.8,,13233.41,399.86,16809.6787,percent of total billed charges,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,AETNA [1000108],AETNA [100010801],,,76.8,,120.58,25.49469,416.02,percent of total billed charges,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,AETNA [1000108],AETNA [100010801],,,76.8,,21.5,6.286,416.02,percent of total billed charges,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,AETNA [1000108],AETNA [100010801],,,76.8,,372.48,108.8825,479.602522,percent of total billed charges,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,AETNA [1000108],AETNA [100010801],,,76.8,,92.16,25.49469,416.02,percent of total billed charges,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,AETNA [1000108],AETNA [100010801],,,76.8,,16.9,4.939,416.02,percent of total billed charges,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,AETNA [1000108],AETNA [100010801],,,76.8,,332.54,84.459332,416.02,percent of total billed charges,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,AETNA [1000108],AETNA [100010801],,,76.8,,244.22,66.75974,416.02,percent of total billed charges,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,AETNA [1000108],AETNA [100010801],,,76.8,,48.38,14.1435,416.02,percent of total billed charges,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,AETNA [1000108],AETNA [100010801],,,76.8,,934.66,41.157815,934.656,percent of total billed charges,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,AETNA [1000108],AETNA [100010801],,,76.8,,1442.3,41.157815,1442.304,percent of total billed charges,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,AETNA [1000108],AETNA [100010801],,,76.8,,172.03,41.157815,416.02,percent of total billed charges,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,AETNA [1000108],AETNA [100010801],,,76.8,,190.46,23.39896,416.02,percent of total billed charges,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,AETNA [1000108],AETNA [100010801],,,76.8,,1026.82,54.1045,1223.3,percent of total billed charges,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,1223.3,percent of total billed charges,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,AETNA [1000108],AETNA [100010801],,,76.8,,1000.7,281.81,1040.64,percent of total billed charges,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,AETNA [1000108],AETNA [100010801],,,76.8,,1040.64,281.81,1040.64,percent of total billed charges,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,AETNA [1000108],AETNA [100010801],,,76.8,,1034.5,54.1045,1034.496,percent of total billed charges,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,AETNA [1000108],AETNA [100010801],,,76.8,,1034.5,54.1045,1034.496,percent of total billed charges,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,1034.496,percent of total billed charges,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,AETNA [1000108],AETNA [100010801],,,76.8,,943.1,267.439885,943.104,percent of total billed charges,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,AETNA [1000108],AETNA [100010801],,,76.8,,943.1,267.439885,943.104,percent of total billed charges,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,AETNA [1000108],AETNA [100010801],,,76.8,,430.85,125.9445,465.66,percent of total billed charges,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,AETNA [1000108],AETNA [100010801],,,76.8,,430.85,125.9445,465.66,percent of total billed charges,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,AETNA [1000108],AETNA [100010801],,,76.8,,430.85,125.9445,465.66,percent of total billed charges,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,AETNA [1000108],AETNA [100010801],,,76.8,,1354.75,224.549385,1354.752,percent of total billed charges,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,AETNA [1000108],AETNA [100010801],,,76.8,,1354.75,224.549385,1354.752,percent of total billed charges,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,AETNA [1000108],AETNA [100010801],,,76.8,,1152.77,336.9745,1152.768,percent of total billed charges,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,79.024,416.02,percent of total billed charges,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,AETNA [1000108],AETNA [100010801],,,76.8,,248.06,72.5135,416.02,percent of total billed charges,
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,AETNA [1000108],AETNA [100010801],,,76.8,,294.91,86.208,416.02,percent of total billed charges,
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,AETNA [1000108],AETNA [100010801],,,76.8,,571.39,135.906309,571.392,percent of total billed charges,
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,AETNA [1000108],AETNA [100010801],,,76.8,,1062.91,224.549385,1062.912,percent of total billed charges,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,AETNA [1000108],AETNA [100010801],,,76.8,,1062.91,224.549385,1062.912,percent of total billed charges,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,AETNA [1000108],AETNA [100010801],,,76.8,,1370.88,224.549385,1370.88,percent of total billed charges,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,AETNA [1000108],AETNA [100010801],,,76.8,,1370.88,224.549385,1370.88,percent of total billed charges,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,AETNA [1000108],AETNA [100010801],,,76.8,,597.5,174.661,597.504,percent of total billed charges,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,AETNA [1000108],AETNA [100010801],,,76.8,,827.14,241.7865,827.136,percent of total billed charges,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,AETNA [1000108],AETNA [100010801],,,76.8,,7047.94,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,AETNA [1000108],AETNA [100010801],,,76.8,,7491.84,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,AETNA [1000108],AETNA [100010801],,,76.8,,7491.84,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,AETNA [1000108],AETNA [100010801],,,76.8,,7960.32,399.86,7960.32,percent of total billed charges,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,AETNA [1000108],AETNA [100010801],,,76.8,,2302.46,399.86,2532.39,percent of total billed charges,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,AETNA [1000108],AETNA [100010801],,,76.8,,2302.46,399.86,2532.39,percent of total billed charges,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,AETNA [1000108],AETNA [100010801],,,76.8,,1952.26,399.86,1952.256,percent of total billed charges,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,AETNA [1000108],AETNA [100010801],,,76.8,,781.82,228.541,1592,percent of total billed charges,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,AETNA [1000108],AETNA [100010801],,,76.8,,391.68,114.495,1592,percent of total billed charges,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,AETNA [1000108],AETNA [100010801],,,76.8,,781.82,228.541,1592,percent of total billed charges,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,AETNA [1000108],AETNA [100010801],,,76.8,,1150.46,235.074116,1592,percent of total billed charges,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,AETNA [1000108],AETNA [100010801],,,76.8,,5326.85,399.86,5638.7,percent of total billed charges,
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,AETNA [1000108],AETNA [100010801],,,76.8,,1575.17,399.86,1575.168,percent of total billed charges,
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,AETNA [1000108],AETNA [100010801],,,76.8,,40899.07,399.86,40899.072,percent of total billed charges,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,AETNA [1000108],AETNA [100010801],,,76.8,,40899.07,399.86,40899.072,percent of total billed charges,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,AETNA [1000108],AETNA [100010801],,,76.8,,40542.72,399.86,40542.72,percent of total billed charges,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,AETNA [1000108],AETNA [100010801],,,76.8,,40542.72,399.86,40542.72,percent of total billed charges,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,AETNA [1000108],AETNA [100010801],,,76.8,,12978.43,399.86,12978.432,percent of total billed charges,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,AETNA [1000108],AETNA [100010801],,,76.8,,6524.93,399.86,6909.98,percent of total billed charges,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,AETNA [1000108],AETNA [100010801],,,76.8,,4525.06,399.86,4525.056,percent of total billed charges,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,AETNA [1000108],AETNA [100010801],,,76.8,,2361.6,399.86,2361.6,percent of total billed charges,
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,AETNA [1000108],AETNA [100010801],,,76.8,,2367.74,399.86,2367.744,percent of total billed charges,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,AETNA [1000108],AETNA [100010801],,,76.8,,2367.74,399.86,2367.744,percent of total billed charges,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,AETNA [1000108],AETNA [100010801],,,76.8,,5905.15,399.86,10671.09667,percent of total billed charges,
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,AETNA [1000108],AETNA [100010801],,,76.8,,934.66,73.54,934.656,percent of total billed charges,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,AETNA [1000108],AETNA [100010801],,,76.8,,195.84,57.2475,416.02,percent of total billed charges,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,AETNA [1000108],AETNA [100010801],,,76.8,,208.13,60.8395,416.02,percent of total billed charges,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,199.512292,702.72,percent of total billed charges,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,119.991125,702.72,percent of total billed charges,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,AETNA [1000108],AETNA [100010801],,,76.8,,873.22,255.2565,873.216,percent of total billed charges,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,AETNA [1000108],AETNA [100010801],,,76.8,,328.7,96.086,686,percent of total billed charges,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,AETNA [1000108],AETNA [100010801],,,76.8,,731.14,213.724,731.136,percent of total billed charges,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,135.906309,702.72,percent of total billed charges,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,AETNA [1000108],AETNA [100010801],,,76.8,,538.37,121.132463,686,percent of total billed charges,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,135.906309,775.5705,percent of total billed charges,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,199.512292,702.72,percent of total billed charges,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,AETNA [1000108],AETNA [100010801],,,76.8,,338.69,99.0045,686,percent of total billed charges,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,135.906309,686,percent of total billed charges,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,135.906309,686,percent of total billed charges,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,119.991125,702.72,percent of total billed charges,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,AETNA [1000108],AETNA [100010801],,,76.8,,582.14,170.171,686,percent of total billed charges,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,AETNA [1000108],AETNA [100010801],,,76.8,,582.14,170.171,686,percent of total billed charges,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,119.991125,702.72,percent of total billed charges,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,AETNA [1000108],AETNA [100010801],,,76.8,,626.69,183.192,686,percent of total billed charges,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,76.8,,321.02,93.841,686,percent of total billed charges,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,199.512292,702.72,percent of total billed charges,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,AETNA [1000108],AETNA [100010801],,,76.8,,297.22,86.8815,686,percent of total billed charges,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,AETNA [1000108],AETNA [100010801],,,76.8,,471.55,119.991125,686,percent of total billed charges,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,AETNA [1000108],AETNA [100010801],,,76.8,,226.56,66.2275,416.02,percent of total billed charges,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,AETNA [1000108],AETNA [100010801],,,76.8,,342.53,100.127,479.602522,percent of total billed charges,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,AETNA [1000108],AETNA [100010801],,,76.8,,710.4,163,710.4,percent of total billed charges,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,AETNA [1000108],AETNA [100010801],,,76.8,,301.06,88.004,416.02,percent of total billed charges,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,AETNA [1000108],AETNA [100010801],,,76.8,,301.06,88.004,416.02,percent of total billed charges,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,AETNA [1000108],AETNA [100010801],,,76.8,,139.78,40.859,416.02,percent of total billed charges,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,AETNA [1000108],AETNA [100010801],,,76.8,,379.39,59.92,416.02,percent of total billed charges,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,AETNA [1000108],AETNA [100010801],,,76.8,,342.53,98.67,479.602522,percent of total billed charges,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,AETNA [1000108],AETNA [100010801],,,76.8,,226.56,66.2275,416.02,percent of total billed charges,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,AETNA [1000108],AETNA [100010801],,,76.8,,203.52,59.4925,416.02,percent of total billed charges,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,AETNA [1000108],AETNA [100010801],,,76.8,,41.47,12.123,416.02,percent of total billed charges,
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,76.8,,69.12,20.205,416.02,percent of total billed charges,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,AETNA [1000108],AETNA [100010801],,,76.8,,148.99,43.553,416.02,percent of total billed charges,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,AETNA [1000108],AETNA [100010801],,,76.8,,148.99,43.553,416.02,percent of total billed charges,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,AETNA [1000108],AETNA [100010801],,,76.8,,281.86,22.74,416.02,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,AETNA [1000108],AETNA [100010801],,,76.8,,1266.43,370.2005,1266.432,percent of total billed charges,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,AETNA [1000108],AETNA [100010801],,,76.8,,1217.28,355.8325,1217.28,percent of total billed charges,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,AETNA [1000108],AETNA [100010801],,,76.8,,1217.28,355.8325,1217.28,percent of total billed charges,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,AETNA [1000108],AETNA [100010801],,,76.8,,623.62,182.294,623.616,percent of total billed charges,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,AETNA [1000108],AETNA [100010801],,,76.8,,735.74,215.071,735.744,percent of total billed charges,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,AETNA [1000108],AETNA [100010801],,,76.8,,538.37,157.3745,538.368,percent of total billed charges,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,AETNA [1000108],AETNA [100010801],,,76.8,,603.65,176.457,603.648,percent of total billed charges,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,AETNA [1000108],AETNA [100010801],,,76.8,,518.4,151.5375,518.4,percent of total billed charges,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,AETNA [1000108],AETNA [100010801],,,76.8,,518.4,151.5375,829.50194,percent of total billed charges,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,AETNA [1000108],AETNA [100010801],,,76.8,,254.98,14.817,570,percent of total billed charges,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,AETNA [1000108],AETNA [100010801],,,76.8,,50.69,14.817,570,percent of total billed charges,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,AETNA [1000108],AETNA [100010801],,,76.8,,254.98,30.083,570,percent of total billed charges,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,AETNA [1000108],AETNA [100010801],,,76.8,,102.91,30.083,570,percent of total billed charges,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,AETNA [1000108],AETNA [100010801],,,76.8,,138.24,20.4295,570,percent of total billed charges,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,AETNA [1000108],AETNA [100010801],,,76.8,,69.89,20.4295,570,percent of total billed charges,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,AETNA [1000108],AETNA [100010801],,,76.8,,583.68,94.4,583.68,percent of total billed charges,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,AETNA [1000108],AETNA [100010801],,,76.8,,534.53,94.4,570,percent of total billed charges,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,AETNA [1000108],AETNA [100010801],,,76.8,,556.03,94.4,570,percent of total billed charges,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,AETNA [1000108],AETNA [100010801],,,76.8,,675.07,197.3355,675.072,percent of total billed charges,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,AETNA [1000108],AETNA [100010801],,,76.8,,534.53,156.252,534.528,percent of total billed charges,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,AETNA [1000108],AETNA [100010801],,,76.8,,256.51,74.983,416.02,percent of total billed charges,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,AETNA [1000108],AETNA [100010801],,,76.8,,68.35,19.9805,585.854902,percent of total billed charges,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,76.8,,321.02,93.841,416.02,percent of total billed charges,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,AETNA [1000108],AETNA [100010801],,,76.8,,101.38,29.634,585.854902,percent of total billed charges,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,AETNA [1000108],AETNA [100010801],,,76.8,,140.54,41.0835,416.02,percent of total billed charges,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,AETNA [1000108],AETNA [100010801],,,76.8,,83.71,24.4705,416.02,percent of total billed charges,
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,AETNA [1000108],AETNA [100010801],,,76.8,,124.42,16.16,416.02,percent of total billed charges,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,AETNA [1000108],AETNA [100010801],,,76.8,,256.51,74.983,416.02,percent of total billed charges,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,AETNA [1000108],AETNA [100010801],,,76.8,,237.31,69.3705,416.02,percent of total billed charges,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,AETNA [1000108],AETNA [100010801],,,76.8,,80.64,23.5725,416.02,percent of total billed charges,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,AETNA [1000108],AETNA [100010801],,,76.8,,232.7,68.0235,416.02,percent of total billed charges,
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,49.839,416.02,percent of total billed charges,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,AETNA [1000108],AETNA [100010801],,,76.8,,530.69,155.1295,530.688,percent of total billed charges,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,AETNA [1000108],AETNA [100010801],,,76.8,,556.03,162.538,556.032,percent of total billed charges,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,AETNA [1000108],AETNA [100010801],,,76.8,,143.62,41.9815,585.854902,percent of total billed charges,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,AETNA [1000108],AETNA [100010801],,,76.8,,513.02,70.143083,517.481916,percent of total billed charges,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,AETNA [1000108],AETNA [100010801],,,76.8,,504.58,147.4965,585.854902,percent of total billed charges,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,AETNA [1000108],AETNA [100010801],,,76.8,,407.04,34.385146,416.02,percent of total billed charges,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,AETNA [1000108],AETNA [100010801],,,76.8,,188.16,14.38,416.02,percent of total billed charges,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,AETNA [1000108],AETNA [100010801],,,76.8,,94.46,27.6135,416.02,percent of total billed charges,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,AETNA [1000108],AETNA [100010801],,,76.8,,94.46,14.73,416.02,percent of total billed charges,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,AETNA [1000108],AETNA [100010801],,,76.8,,142.08,20.02,416.02,percent of total billed charges,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,14.44,416.02,percent of total billed charges,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,14.44,416.02,percent of total billed charges,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,AETNA [1000108],AETNA [100010801],,,76.8,,151.3,30.33,416.02,percent of total billed charges,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,AETNA [1000108],AETNA [100010801],,,76.8,,151.3,30.33,416.02,percent of total billed charges,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,AETNA [1000108],AETNA [100010801],,,76.8,,107.52,27.89,416.02,percent of total billed charges,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,AETNA [1000108],AETNA [100010801],,,76.8,,107.52,27.89,416.02,percent of total billed charges,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,AETNA [1000108],AETNA [100010801],,,76.8,,99.84,18.56,416.02,percent of total billed charges,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,AETNA [1000108],AETNA [100010801],,,76.8,,99.84,18.56,416.02,percent of total billed charges,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,AETNA [1000108],AETNA [100010801],,,76.8,,199.68,58.37,416.02,percent of total billed charges,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,AETNA [1000108],AETNA [100010801],,,76.8,,199.68,58.37,416.02,percent of total billed charges,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,AETNA [1000108],AETNA [100010801],,,76.8,,199.68,58.37,416.02,percent of total billed charges,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,AETNA [1000108],AETNA [100010801],,,76.8,,177.41,51.8595,416.02,percent of total billed charges,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,AETNA [1000108],AETNA [100010801],,,76.8,,79.87,23.348,416.02,percent of total billed charges,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,AETNA [1000108],AETNA [100010801],,,76.8,,139.78,34.45,416.02,percent of total billed charges,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,AETNA [1000108],AETNA [100010801],,,76.8,,81.41,23.797,416.02,percent of total billed charges,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,AETNA [1000108],AETNA [100010801],,,76.8,,39.94,11.674,416.02,percent of total billed charges,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,AETNA [1000108],AETNA [100010801],,,76.8,,176.64,51.635,416.02,percent of total billed charges,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,AETNA [1000108],AETNA [100010801],,,76.8,,277.25,81.0445,416.02,percent of total billed charges,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,AETNA [1000108],AETNA [100010801],,,76.8,,253.44,74.085,416.02,percent of total billed charges,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,76.8,,239.62,70.044,416.02,percent of total billed charges,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,AETNA [1000108],AETNA [100010801],,,,,,82.56,416.02,other,E&M in Hospital/Facility
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,AETNA [1000108],AETNA [100010801],,,,,,126.37,473.871,other,E&M in Hospital/Facility
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,AETNA [1000108],AETNA [100010801],,,,,,179.35,693.026,other,E&M in Hospital/Facility
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,AETNA [1000108],AETNA [100010801],,,,,,146.954008,985.784,other,E&M in Hospital/Facility
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,,,,18.1184,416.02,other,E&M in Hospital/Facility
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,,,,18.1184,416.02,other,E&M in Hospital/Facility
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,76.8,,220.42,18.1184,416.02,percent of total billed charges,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,,,,50.2428,416.02,other,E&M in Hospital/Facility
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,76.8,,302.59,50.2428,416.02,percent of total billed charges,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,AETNA [1000108],AETNA [100010801],,,76.8,,286.46,50.2428,416.02,percent of total billed charges,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,AETNA [1000108],AETNA [100010801],,,,,,90.68,416.02,other,E&M in Hospital/Facility
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,AETNA [1000108],AETNA [100010801],,,76.8,,331.01,90.68,416.02,percent of total billed charges,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,AETNA [1000108],AETNA [100010801],,,,,,104.8415,416.02,other,E&M in Hospital/Facility
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,AETNA [1000108],AETNA [100010801],,,76.8,,358.66,104.8415,416.02,percent of total billed charges,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,AETNA [1000108],AETNA [100010801],,,,,,169.273,685.583,other,E&M in Hospital/Facility
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,AETNA [1000108],AETNA [100010801],,,76.8,,579.07,169.273,685.583,percent of total billed charges,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,AETNA [1000108],AETNA [100010801],,,76.8,,2424.58,318.748996,2424.576,percent of total billed charges,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,AETNA [1000108],AETNA [100010801],,,76.8,,2424.58,318.748996,2424.576,percent of total billed charges,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,AETNA [1000108],AETNA [100010801],,,76.8,,699.65,204.5195,699.648,percent of total billed charges,
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,AETNA [1000108],AETNA [100010801],,,76.8,,699.65,204.5195,699.648,percent of total billed charges,
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,AETNA [1000108],AETNA [100010801],,,76.8,,164.35,31.31797,416.02,percent of total billed charges,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,AETNA [1000108],AETNA [100010801],,,76.8,,164.35,31.31797,416.02,percent of total billed charges,
TPN ELECTROLYTES IV CONC,RX-110242,CDM,25000001,HCPCS,250,RC,00409-5779-01,NDC,outpatient,20,ML,32.85,22.995,AETNA [1000108],AETNA [100010801],,,76.8,,25.23,0.74534,528.0548,percent of total billed charges,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,AETNA [1000108],AETNA [100010801],,,76.8,,19.04,0.74534,528.0548,percent of total billed charges,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,99999-0003-10,NDC,outpatient,10,ML,15.37,10.759,AETNA [1000108],AETNA [100010801],,,76.8,,11.8,0.74534,528.0548,percent of total billed charges,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,AETNA [1000108],AETNA [100010801],,,76.8,,18.29,0.74534,528.0548,percent of total billed charges,
TALC 4 G PL POWD,RX-142785,CDM,25000001,HCPCS,250,RC,62327-0444-04,NDC,outpatient,1,UN,623,436.1,AETNA [1000108],AETNA [100010801],,,76.8,,478.46,0.74534,528.0548,percent of total billed charges,
TALC 4 G PL POWD,RX-142785,CDM,25000001,HCPCS,250,RC,62327-0444-44,NDC,outpatient,1,UN,623,436.1,AETNA [1000108],AETNA [100010801],,,76.8,,478.46,0.74534,528.0548,percent of total billed charges,
HYPERLYTE-CR IV CONC,RX-150262,CDM,25000001,HCPCS,250,RC,00409-5779-01,NDC,outpatient,20,ML,32.85,22.995,AETNA [1000108],AETNA [100010801],,,76.8,,25.23,0.74534,528.0548,percent of total billed charges,
HYPERLYTE-CR IV CONC,RX-150262,CDM,25000001,HCPCS,250,RC,00409-5779-11,NDC,outpatient,20,ML,32.85,22.995,AETNA [1000108],AETNA [100010801],,,76.8,,25.23,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0202-06,NDC,outpatient,1000,ML,162.85,113.995,AETNA [1000108],AETNA [100010801],,,76.8,,125.07,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0202-01,NDC,outpatient,1000,ML,162.85,113.995,AETNA [1000108],AETNA [100010801],,,76.8,,125.07,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0206-04,NDC,outpatient,2000,ML,283,198.1,AETNA [1000108],AETNA [100010801],,,76.8,,217.34,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0206-01,NDC,outpatient,2000,ML,283,198.1,AETNA [1000108],AETNA [100010801],,,76.8,,217.34,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0210-01,NDC,outpatient,1000,ML,153.95,107.765,AETNA [1000108],AETNA [100010801],,,76.8,,118.23,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0210-06,NDC,outpatient,1000,ML,153.95,107.765,AETNA [1000108],AETNA [100010801],,,76.8,,118.23,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0214-01,NDC,outpatient,2000,ML,238.5,166.95,AETNA [1000108],AETNA [100010801],,,76.8,,183.17,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0214-04,NDC,outpatient,2000,ML,238.5,166.95,AETNA [1000108],AETNA [100010801],,,76.8,,183.17,0.74534,528.0548,percent of total billed charges,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-152285,CDM,25000001,HCPCS,250,RC,00338-0184-01,NDC,outpatient,2000,ML,274.1,191.87,AETNA [1000108],AETNA [100010801],,,76.8,,210.51,0.74534,528.0548,percent of total billed charges,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-152285,CDM,25000001,HCPCS,250,RC,00338-0184-04,NDC,outpatient,2000,ML,274.1,191.87,AETNA [1000108],AETNA [100010801],,,76.8,,210.51,0.74534,528.0548,percent of total billed charges,
CLINIMIX/DEXTROSE (8/10) 8 % IV SOLN,RX-152286,CDM,25000001,HCPCS,250,RC,00338-0194-04,NDC,outpatient,2000,ML,229.6,160.72,AETNA [1000108],AETNA [100010801],,,76.8,,176.33,0.74534,528.0548,percent of total billed charges,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-156196,CDM,25000001,HCPCS,250,RC,00517-9302-01,NDC,outpatient,1,ML,76.19,53.333,AETNA [1000108],AETNA [100010801],,,76.8,,58.51,0.74534,528.0548,percent of total billed charges,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-156196,CDM,25000001,HCPCS,250,RC,00517-9302-25,NDC,outpatient,1,ML,76.19,53.333,AETNA [1000108],AETNA [100010801],,,76.8,,58.51,0.74534,528.0548,percent of total billed charges,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-07,NDC,outpatient,500,ML,69.4,48.58,AETNA [1000108],AETNA [100010801],,,76.8,,53.3,0.74534,528.0548,percent of total billed charges,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-02,NDC,outpatient,250,ML,57.17,40.019,AETNA [1000108],AETNA [100010801],,,76.8,,43.91,0.74534,528.0548,percent of total billed charges,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-06,NDC,outpatient,250,ML,57.17,40.019,AETNA [1000108],AETNA [100010801],,,76.8,,43.91,0.74534,528.0548,percent of total billed charges,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-03,NDC,outpatient,500,ML,69.4,48.58,AETNA [1000108],AETNA [100010801],,,76.8,,53.3,0.74534,528.0548,percent of total billed charges,
PRISMASOL BGK 4/0/1.2 32-4-1.2 MEQ/L EC SOLN,RX-156745,CDM,25000001,HCPCS,250,RC,24571-0114-06,NDC,outpatient,5000,ML,294.88,206.416,AETNA [1000108],AETNA [100010801],,,76.8,,226.47,0.74534,528.0548,percent of total billed charges,
MORPHINE SULFATE 100 MG IN D5W 100 ML PREMIX,RX-166979,CDM,25000001,HCPCS,250,RC,99999-0003-25,NDC,outpatient,100,ML,48.85,34.195,AETNA [1000108],AETNA [100010801],,,76.8,,37.52,0.74534,528.0548,percent of total billed charges,
ALUMINUM POTASSIUM SULFATE POWD,RX-21429,CDM,25000001,HCPCS,250,RC,24357-0300-30,NDC,outpatient,10,GR,267.27,187.089,AETNA [1000108],AETNA [100010801],,,76.8,,205.26,0.74534,528.0548,percent of total billed charges,
TROPHAMINE 10 % IV SOLN,RX-25798,CDM,25000001,HCPCS,250,RC,00264-1933-10,NDC,outpatient,500,ML,198.45,138.915,AETNA [1000108],AETNA [100010801],,,76.8,,152.41,0.74534,528.0548,percent of total billed charges,
GENTAMICIN IV SYRINGE 4 MG/ML (PEDIATRIC),RX-400058,CDM,25000001,HCPCS,250,RC,99999-0000-52,NDC,outpatient,10,ML,50.94,35.658,AETNA [1000108],AETNA [100010801],,,76.8,,39.12,0.74534,528.0548,percent of total billed charges,
GENTAMICIN IV SYRINGE 4 MG/ML (PEDIATRIC),RX-400058,CDM,25000001,HCPCS,250,RC,99999-0001-20,NDC,outpatient,5,ML,36.18,25.326,AETNA [1000108],AETNA [100010801],,,76.8,,27.79,0.74534,528.0548,percent of total billed charges,
AMINOCAPROIC ACID INFUSION (OPEN HEART),RX-400081,CDM,25000001,HCPCS,250,RC,99999-0000-86,NDC,outpatient,150,ML,97.97,68.579,AETNA [1000108],AETNA [100010801],,,76.8,,75.24,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,25000001,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,25000001,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,6.43,4.501,AETNA [1000108],AETNA [100010801],,,76.8,,4.94,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,AETNA [1000108],AETNA [100010801],,,76.8,,7.54,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,AETNA [1000108],AETNA [100010801],,,76.8,,7.54,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,AETNA [1000108],AETNA [100010801],,,76.8,,10.66,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,AETNA [1000108],AETNA [100010801],,,76.8,,2.76,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,AETNA [1000108],AETNA [100010801],,,76.8,,10.66,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00338-0013-04,NDC,outpatient,1000,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-23,NDC,outpatient,20,ML,4.84,3.388,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,AETNA [1000108],AETNA [100010801],,,76.8,,2.76,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-20,NDC,outpatient,20,ML,4.84,3.388,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,AETNA [1000108],AETNA [100010801],,,76.8,,3.13,0.74534,528.0548,percent of total billed charges,
SUGAMMADEX SODIUM 100 MG/ML IV SOLN WRAPPER,RX-4080830,CDM,25000001,HCPCS,250,RC,00006-5423-02,NDC,outpatient,2,ML,533.12,373.184,AETNA [1000108],AETNA [100010801],,,76.8,,409.44,0.74534,528.0548,percent of total billed charges,
SUGAMMADEX SODIUM 100 MG/ML IV SOLN WRAPPER,RX-4080830,CDM,25000001,HCPCS,250,RC,00006-5423-12,NDC,outpatient,2,ML,533.12,373.184,AETNA [1000108],AETNA [100010801],,,76.8,,409.44,0.74534,528.0548,percent of total billed charges,
DEXMEDETOMIDINE HCL IN NACL 4 MCG/ML IV SOLN WRAPPER,RX-4080915,CDM,25000001,HCPCS,250,RC,00338-9557-12,NDC,outpatient,100,ML,89.43,62.601,AETNA [1000108],AETNA [100010801],,,76.8,,68.68,0.74534,528.0548,percent of total billed charges,
DILTIAZEM 100 MG IN 100 ML D5W BATCHED INFUSION,RX-4080938,CDM,25000001,HCPCS,250,RC,99999-0000-30,NDC,outpatient,100,ML,48.09,33.663,AETNA [1000108],AETNA [100010801],,,76.8,,36.93,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % CRRT SOLN,RX-4081079,CDM,25000001,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % CRRT SOLN,RX-4081079,CDM,25000001,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,0.74534,528.0548,percent of total billed charges,
FAMOTIDINE IN NS (NEO/PEDI) SYRINGE 0.4 MG/ML,RX-4081338,CDM,25000001,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,AETNA [1000108],AETNA [100010801],,,76.8,,18.61,0.74534,528.0548,percent of total billed charges,
PANTOPRAZOLE 80 MG/100 ML BOLUS/LOADING DOSE PREMIX,RX-4081495,CDM,25000001,HCPCS,250,RC,99999-0004-21,NDC,outpatient,100,ML,36.56,25.592,AETNA [1000108],AETNA [100010801],,,76.8,,28.08,0.74534,528.0548,percent of total billed charges,
CARDIOPLEGIA SOLN HIGH POTASSIUM 60 MEQ + MG 65 MEQ IN 500 ML OF NS,RX-4081526,CDM,25000001,HCPCS,250,RC,99999-0004-32,NDC,outpatient,500,ML,78.75,55.125,AETNA [1000108],AETNA [100010801],,,76.8,,60.48,0.74534,528.0548,percent of total billed charges,
VANCOMYCIN INTRAOSSEOUS 500 MG/50 ML NS SYR,RX-4081621,CDM,25000001,HCPCS,250,RC,99999-0004-52,NDC,outpatient,50,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.74534,528.0548,percent of total billed charges,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,25000001,HCPCS,250,RC,00338-0644-04,NDC,outpatient,1000,ML,78.3,54.81,AETNA [1000108],AETNA [100010801],,,76.8,,60.13,0.74534,528.0548,percent of total billed charges,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,25000001,HCPCS,250,RC,00338-0644-06,NDC,outpatient,2000,ML,122.8,85.96,AETNA [1000108],AETNA [100010801],,,76.8,,94.31,0.74534,528.0548,percent of total billed charges,
ZINC OXIDE 16 % EX OINT,RX-109467,CDM,25900001,HCPCS,259,RC,62103-0333-04,NDC,outpatient,113,GR,20.62,14.434,AETNA [1000108],AETNA [100010801],,,76.8,,15.84,0.222255,1203.778472,percent of total billed charges,
GLYCOPYRROLATE-FORMOTEROL 9-4.8 MCG/ACT IN AERO,RX-135283,CDM,25900001,HCPCS,259,RC,00310-4600-12,NDC,outpatient,10.7,GR,1420.22,994.154,AETNA [1000108],AETNA [100010801],,,76.8,,1090.73,0.222255,1203.778472,percent of total billed charges,
MULTIVITAMINS PLUS IRON CHILD 18 MG ORAL CHEW,RX-138485,CDM,25900001,HCPCS,259,RC,16500-0599-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,1203.778472,percent of total billed charges,
MULTIVITAMINS PLUS IRON CHILD 18 MG ORAL CHEW,RX-138485,CDM,25900001,HCPCS,259,RC,16500-0079-09,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,1203.778472,percent of total billed charges,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148710,CDM,25900001,HCPCS,259,RC,39328-0062-50,NDC,outpatient,473,ML,44.21,30.947,AETNA [1000108],AETNA [100010801],,,76.8,,33.95,0.222255,1203.778472,percent of total billed charges,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148710,CDM,25900001,HCPCS,259,RC,00436-0946-16,NDC,outpatient,473,ML,52.63,36.841,AETNA [1000108],AETNA [100010801],,,76.8,,40.42,0.222255,1203.778472,percent of total billed charges,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,10631-0407-01,NDC,outpatient,28.35,GR,38.36,26.852,AETNA [1000108],AETNA [100010801],,,76.8,,29.46,0.222255,1203.778472,percent of total billed charges,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,62559-0431-30,NDC,outpatient,30,GR,76.9,53.83,AETNA [1000108],AETNA [100010801],,,76.8,,59.06,0.222255,1203.778472,percent of total billed charges,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,64980-0324-30,NDC,outpatient,30,GR,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.222255,1203.778472,percent of total billed charges,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,69315-0312-28,NDC,outpatient,28,GR,33.65,23.555,AETNA [1000108],AETNA [100010801],,,76.8,,25.84,0.222255,1203.778472,percent of total billed charges,
PRAMOXINE HCL (PERIANAL) 1 % EX FOAM,RX-150306,CDM,25900001,HCPCS,259,RC,51862-0180-15,NDC,outpatient,15,GR,166.95,116.865,AETNA [1000108],AETNA [100010801],,,76.8,,128.22,0.222255,1203.778472,percent of total billed charges,
HYDROCORT-PRAMOXINE (PERIANAL) 1-1 % EX FOAM,RX-150328,CDM,25900001,HCPCS,259,RC,00037-6822-10,NDC,outpatient,10,GR,761.13,532.791,AETNA [1000108],AETNA [100010801],,,76.8,,584.55,0.222255,1203.778472,percent of total billed charges,
PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG ORAL TABS,RX-155613,CDM,25900001,HCPCS,259,RC,76385-0102-01,NDC,outpatient,1,UN,5.96,4.172,AETNA [1000108],AETNA [100010801],,,76.8,,4.58,0.222255,1203.778472,percent of total billed charges,
ZANAMIVIR 5 MG/ACT IN AEPB,RX-160595,CDM,25900001,HCPCS,259,RC,00173-0681-01,NDC,outpatient,20,UN,240.22,168.154,AETNA [1000108],AETNA [100010801],,,76.8,,184.49,0.222255,1203.778472,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % EX CREA,RX-16299,CDM,25900001,HCPCS,259,RC,45802-0358-03,NDC,outpatient,28,GR,4.62,3.234,AETNA [1000108],AETNA [100010801],,,76.8,,3.55,0.222255,1203.778472,percent of total billed charges,
GLYCERIN (LIQUID) 2.8 G RE SUPP,RX-163739,CDM,25900001,HCPCS,259,RC,00132-0190-12,NDC,outpatient,4,ML,3,2.1,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,1203.778472,percent of total billed charges,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,63739-0157-10,NDC,outpatient,5,ML,6.5,4.55,AETNA [1000108],AETNA [100010801],,,76.8,,4.99,0.222255,1203.778472,percent of total billed charges,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,63739-0157-70,NDC,outpatient,5,ML,6.5,4.55,AETNA [1000108],AETNA [100010801],,,76.8,,4.99,0.222255,1203.778472,percent of total billed charges,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,00121-0530-05,NDC,outpatient,5,ML,13.51,9.457,AETNA [1000108],AETNA [100010801],,,76.8,,10.38,0.222255,1203.778472,percent of total billed charges,
PSYLLIUM 25 % ORAL PACK,RX-166710,CDM,25900001,HCPCS,259,RC,37000-0023-04,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,1203.778472,percent of total billed charges,
PSYLLIUM 25 % ORAL PACK,RX-166710,CDM,25900001,HCPCS,259,RC,37000-0023-10,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,1203.778472,percent of total billed charges,
ASTROGLIDE EX GEL,RX-23759,CDM,25900001,HCPCS,259,RC,15594-0010-07,NDC,outpatient,66.5,GR,20.13,14.091,AETNA [1000108],AETNA [100010801],,,76.8,,15.46,0.222255,1203.778472,percent of total billed charges,
CORN STARCH EX POWD,RX-28839,CDM,25900001,HCPCS,259,RC,00316-0233-25,NDC,outpatient,71,GR,13.91,9.737,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,0.222255,1203.778472,percent of total billed charges,
GLYCERIN (LAXATIVE) 5.4 GM/DOSE RE ENEM,RX-37495,CDM,25900001,HCPCS,259,RC,00132-0185-01,NDC,outpatient,7.5,ML,3.54,2.478,AETNA [1000108],AETNA [100010801],,,76.8,,2.72,0.222255,1203.778472,percent of total billed charges,
GLYCERIN (LAXATIVE) 5.4 GM/DOSE RE ENEM,RX-37495,CDM,25900001,HCPCS,259,RC,00132-0185-82,NDC,outpatient,7.5,ML,3.54,2.478,AETNA [1000108],AETNA [100010801],,,76.8,,2.72,0.222255,1203.778472,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG/ML ORAL SOLN,RX-3782,CDM,25900001,HCPCS,259,RC,54838-0506-15,NDC,outpatient,15,ML,121.96,85.372,AETNA [1000108],AETNA [100010801],,,76.8,,93.67,0.222255,1203.778472,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG/ML ORAL SOLN,RX-3782,CDM,25900001,HCPCS,259,RC,39328-0047-15,NDC,outpatient,15,ML,86.71,60.697,AETNA [1000108],AETNA [100010801],,,76.8,,66.59,0.222255,1203.778472,percent of total billed charges,
GENTAMICIN FORTIFIED EYE SOLUTION 14 MG/ML,RX-4080014,CDM,25900001,HCPCS,259,RC,99999-0001-32,NDC,outpatient,7,ML,17.67,12.369,AETNA [1000108],AETNA [100010801],,,76.8,,13.57,0.222255,1203.778472,percent of total billed charges,
LACTULOSE ENEMA IN STERILE WATER 1000 ML,RX-4080406,CDM,25900001,HCPCS,259,RC,,,outpatient,1000,ML,16.47,11.529,AETNA [1000108],AETNA [100010801],,,76.8,,12.65,0.222255,1203.778472,percent of total billed charges,
LACTULOSE ENEMA IN SODIUM CHLORIDE 0.9 % 1000 ML,RX-4080407,CDM,25900001,HCPCS,259,RC,99999-0001-00,NDC,outpatient,1000,ML,16.47,11.529,AETNA [1000108],AETNA [100010801],,,76.8,,12.65,0.222255,1203.778472,percent of total billed charges,
WITCH HAZEL-GLYCERIN EX PADS WRAPPER,RX-4080503,CDM,25900001,HCPCS,259,RC,50289-3250-01,NDC,outpatient,40,UN,9.62,6.734,AETNA [1000108],AETNA [100010801],,,76.8,,7.39,0.222255,1203.778472,percent of total billed charges,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3015-05,NDC,outpatient,20,ML,33.02,23.114,AETNA [1000108],AETNA [100010801],,,76.8,,25.36,0.222255,1203.778472,percent of total billed charges,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3013-05,NDC,outpatient,10,ML,24.12,16.884,AETNA [1000108],AETNA [100010801],,,76.8,,18.52,0.222255,1203.778472,percent of total billed charges,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3011-05,NDC,outpatient,5,ML,18.29,12.803,AETNA [1000108],AETNA [100010801],,,76.8,,14.05,0.222255,1203.778472,percent of total billed charges,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3012-05,NDC,outpatient,5,ML,18.29,12.803,AETNA [1000108],AETNA [100010801],,,76.8,,14.05,0.222255,1203.778472,percent of total billed charges,
CLONIDINE NEONATAL SUSPENSION 5 MCG/ML,RX-4080796,CDM,25900001,HCPCS,259,RC,99999-0001-04,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,1203.778472,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLN WRAPPER,RX-4081075,CDM,25900001,HCPCS,259,RC,99999-0000-64,NDC,outpatient,2.5,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.222255,1203.778472,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLN WRAPPER,RX-4081075,CDM,25900001,HCPCS,259,RC,65628-0206-05,NDC,outpatient,2.5,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.222255,1203.778472,percent of total billed charges,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,41100-0015-11,NDC,outpatient,15,ML,31.71,22.197,AETNA [1000108],AETNA [100010801],,,76.8,,24.35,0.222255,1203.778472,percent of total billed charges,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,41100-0811-23,NDC,outpatient,15,ML,25.17,17.619,AETNA [1000108],AETNA [100010801],,,76.8,,19.33,0.222255,1203.778472,percent of total billed charges,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,49348-0130-27,NDC,outpatient,30,ML,16.69,11.683,AETNA [1000108],AETNA [100010801],,,76.8,,12.82,0.222255,1203.778472,percent of total billed charges,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,00904-7006-35,NDC,outpatient,15,ML,6.41,4.487,AETNA [1000108],AETNA [100010801],,,76.8,,4.92,0.222255,1203.778472,percent of total billed charges,
SULFUR PRECIPITATED POWD,RX-7576,CDM,25900001,HCPCS,259,RC,38779-0098-08,NDC,outpatient,500,GR,142.38,99.666,AETNA [1000108],AETNA [100010801],,,76.8,,109.35,0.222255,1203.778472,percent of total billed charges,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,AETNA [1000108],AETNA [100010801],,,76.8,,90.49,0.222255,1203.778472,percent of total billed charges,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,AETNA [1000108],AETNA [100010801],,,76.8,,71.03,0.222255,1203.778472,percent of total billed charges,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,AETNA [1000108],AETNA [100010801],,,76.8,,112.64,0.222255,1203.778472,percent of total billed charges,
DESMOPRESSIN ACE REFRIGERATED 0.01 % NA SOLN,RX-9749,CDM,25900001,HCPCS,259,RC,55566-2400-00,NDC,outpatient,2.5,ML,1134.27,793.989,AETNA [1000108],AETNA [100010801],,,76.8,,871.12,0.222255,1203.778472,percent of total billed charges,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,outpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,76.8,,69.12,20.205,72,percent of total billed charges,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,94.4,percent of total billed charges,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,outpatient,,,113,79.1,AETNA [1000108],AETNA [100010801],,,76.8,,86.78,25.3685,90.4,percent of total billed charges,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,outpatient,,,80,56,AETNA [1000108],AETNA [100010801],,,76.8,,61.44,17.96,64,percent of total billed charges,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,outpatient,,,79,55.3,AETNA [1000108],AETNA [100010801],,,76.8,,60.67,17.7355,63.2,percent of total billed charges,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,outpatient,,,267,186.9,AETNA [1000108],AETNA [100010801],,,76.8,,205.06,59.9415,213.6,percent of total billed charges,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,outpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,76.8,,69.12,20.205,72,percent of total billed charges,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,outpatient,,,282,197.4,AETNA [1000108],AETNA [100010801],,,76.8,,216.58,63.309,225.6,percent of total billed charges,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,outpatient,,,268,187.6,AETNA [1000108],AETNA [100010801],,,76.8,,205.82,60.166,214.4,percent of total billed charges,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,outpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,76.8,,217.34,63.5335,226.4,percent of total billed charges,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,outpatient,,,285,199.5,AETNA [1000108],AETNA [100010801],,,76.8,,218.88,63.9825,228,percent of total billed charges,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,76.8,,220.42,64.4315,229.6,percent of total billed charges,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,outpatient,,,307,214.9,AETNA [1000108],AETNA [100010801],,,76.8,,235.78,68.9215,245.6,percent of total billed charges,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,outpatient,,,423,296.1,AETNA [1000108],AETNA [100010801],,,76.8,,324.86,94.9635,338.4,percent of total billed charges,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,outpatient,,,438,306.6,AETNA [1000108],AETNA [100010801],,,76.8,,336.38,98.331,350.4,percent of total billed charges,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,outpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,76.8,,406.27,118.7605,423.2,percent of total billed charges,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,outpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,76.8,,406.27,118.7605,423.2,percent of total billed charges,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,outpatient,,,816,571.2,AETNA [1000108],AETNA [100010801],,,76.8,,626.69,183.192,652.8,percent of total billed charges,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,outpatient,,,3884,2718.8,AETNA [1000108],AETNA [100010801],,,76.8,,2982.91,871.958,3107.2,percent of total billed charges,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,outpatient,,,4891,3423.7,AETNA [1000108],AETNA [100010801],,,76.8,,3756.29,1098.0295,3912.8,percent of total billed charges,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,outpatient,,,5242,3669.4,AETNA [1000108],AETNA [100010801],,,76.8,,4025.86,1176.829,4193.6,percent of total billed charges,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,outpatient,,,5466,3826.2,AETNA [1000108],AETNA [100010801],,,76.8,,4197.89,1227.117,4372.8,percent of total billed charges,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,outpatient,,,667,466.9,AETNA [1000108],AETNA [100010801],,,76.8,,512.26,149.7415,533.6,percent of total billed charges,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,outpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,76.8,,271.1,79.2485,282.4,percent of total billed charges,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,outpatient,,,327,228.9,AETNA [1000108],AETNA [100010801],,,76.8,,251.14,73.4115,261.6,percent of total billed charges,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,outpatient,,,390,273,AETNA [1000108],AETNA [100010801],,,76.8,,299.52,87.555,312,percent of total billed charges,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,outpatient,,,707,494.9,AETNA [1000108],AETNA [100010801],,,76.8,,542.98,158.7215,565.6,percent of total billed charges,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,outpatient,,,144,100.8,AETNA [1000108],AETNA [100010801],,,76.8,,110.59,32.328,122.0544,percent of total billed charges,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,222.0712,percent of total billed charges,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,outpatient,,,272,190.4,AETNA [1000108],AETNA [100010801],,,76.8,,208.9,61.064,230.5472,percent of total billed charges,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,76.8,,235.01,68.697,259.3656,percent of total billed charges,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,outpatient,,,377,263.9,AETNA [1000108],AETNA [100010801],,,76.8,,289.54,84.6365,319.5452,percent of total billed charges,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,outpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,76.8,,361.73,105.7395,399.2196,percent of total billed charges,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,outpatient,,,490,343,AETNA [1000108],AETNA [100010801],,,76.8,,376.32,110.005,415.324,percent of total billed charges,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,outpatient,,,939,657.3,AETNA [1000108],AETNA [100010801],,,76.8,,721.15,210.8055,795.8964,percent of total billed charges,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,outpatient,,,88,61.6,AETNA [1000108],AETNA [100010801],,,76.8,,67.58,19.756,74.5888,percent of total billed charges,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,outpatient,,,95,66.5,AETNA [1000108],AETNA [100010801],,,76.8,,72.96,21.3275,80.522,percent of total billed charges,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,outpatient,,,108,75.6,AETNA [1000108],AETNA [100010801],,,76.8,,82.94,24.246,91.5408,percent of total billed charges,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,outpatient,,,128,89.6,AETNA [1000108],AETNA [100010801],,,76.8,,98.3,28.736,108.4928,percent of total billed charges,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,43.3285,163.5868,percent of total billed charges,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,outpatient,,,195,136.5,AETNA [1000108],AETNA [100010801],,,76.8,,149.76,43.7775,165.282,percent of total billed charges,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,outpatient,,,225,157.5,AETNA [1000108],AETNA [100010801],,,76.8,,172.8,50.5125,190.71,percent of total billed charges,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,80.1465,302.5932,percent of total billed charges,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,80.1465,302.5932,percent of total billed charges,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,80.1465,302.5932,percent of total billed charges,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,outpatient,,,374,261.8,AETNA [1000108],AETNA [100010801],,,76.8,,287.23,83.963,317.0024,percent of total billed charges,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,outpatient,,,396,277.2,AETNA [1000108],AETNA [100010801],,,76.8,,304.13,88.902,335.6496,percent of total billed charges,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,outpatient,,,402,281.4,AETNA [1000108],AETNA [100010801],,,76.8,,308.74,90.249,340.7352,percent of total billed charges,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,outpatient,,,409,286.3,AETNA [1000108],AETNA [100010801],,,76.8,,314.11,91.8205,346.6684,percent of total billed charges,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,outpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,76.8,,321.02,93.841,354.2968,percent of total billed charges,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,outpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,76.8,,320.26,93.6165,353.4492,percent of total billed charges,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,outpatient,,,446,312.2,AETNA [1000108],AETNA [100010801],,,76.8,,342.53,100.127,378.0296,percent of total billed charges,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,outpatient,,,451,315.7,AETNA [1000108],AETNA [100010801],,,76.8,,346.37,101.2495,382.2676,percent of total billed charges,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,104.617,394.9816,percent of total billed charges,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,104.617,394.9816,percent of total billed charges,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,outpatient,,,470,329,AETNA [1000108],AETNA [100010801],,,76.8,,360.96,105.515,398.372,percent of total billed charges,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,outpatient,,,488,341.6,AETNA [1000108],AETNA [100010801],,,76.8,,374.78,109.556,413.6288,percent of total billed charges,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,outpatient,,,516,361.2,AETNA [1000108],AETNA [100010801],,,76.8,,396.29,115.842,437.3616,percent of total billed charges,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,outpatient,,,519,363.3,AETNA [1000108],AETNA [100010801],,,76.8,,398.59,116.5155,439.9044,percent of total billed charges,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,outpatient,,,523,366.1,AETNA [1000108],AETNA [100010801],,,76.8,,401.66,117.4135,443.2948,percent of total billed charges,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,outpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,76.8,,415.49,121.4545,458.5516,percent of total billed charges,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,outpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,76.8,,415.49,121.4545,458.5516,percent of total billed charges,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,outpatient,,,556,389.2,AETNA [1000108],AETNA [100010801],,,76.8,,427.01,124.822,471.2656,percent of total billed charges,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,outpatient,,,674,471.8,AETNA [1000108],AETNA [100010801],,,76.8,,517.63,151.313,571.2824,percent of total billed charges,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,outpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,76.8,,532.99,155.803,588.2344,percent of total billed charges,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,outpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,76.8,,532.99,155.803,588.2344,percent of total billed charges,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,outpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,76.8,,532.99,155.803,588.2344,percent of total billed charges,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,outpatient,,,703,492.1,AETNA [1000108],AETNA [100010801],,,76.8,,539.9,157.8235,595.8628,percent of total billed charges,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,outpatient,,,719,503.3,AETNA [1000108],AETNA [100010801],,,76.8,,552.19,161.4155,609.4244,percent of total billed charges,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,outpatient,,,722,505.4,AETNA [1000108],AETNA [100010801],,,76.8,,554.5,162.089,611.9672,percent of total billed charges,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,outpatient,,,731,511.7,AETNA [1000108],AETNA [100010801],,,76.8,,561.41,164.1095,619.5956,percent of total billed charges,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,outpatient,,,765,535.5,AETNA [1000108],AETNA [100010801],,,76.8,,587.52,171.7425,648.414,percent of total billed charges,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,outpatient,,,776,543.2,AETNA [1000108],AETNA [100010801],,,76.8,,595.97,174.212,657.7376,percent of total billed charges,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,outpatient,,,776,543.2,AETNA [1000108],AETNA [100010801],,,76.8,,595.97,174.212,657.7376,percent of total billed charges,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,716.222,percent of total billed charges,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,716.222,percent of total billed charges,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,716.222,percent of total billed charges,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,outpatient,,,895,626.5,AETNA [1000108],AETNA [100010801],,,76.8,,687.36,200.9275,758.602,percent of total billed charges,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,outpatient,,,895,626.5,AETNA [1000108],AETNA [100010801],,,76.8,,687.36,200.9275,758.602,percent of total billed charges,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,700.9652,percent of total billed charges,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,outpatient,,,939,657.3,AETNA [1000108],AETNA [100010801],,,76.8,,721.15,210.8055,795.8964,percent of total billed charges,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,outpatient,,,979,685.3,AETNA [1000108],AETNA [100010801],,,76.8,,751.87,219.7855,829.8004,percent of total billed charges,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,outpatient,,,1581,1106.7,AETNA [1000108],AETNA [100010801],,,76.8,,1214.21,354.9345,1340.0556,percent of total billed charges,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,outpatient,,,1581,1106.7,AETNA [1000108],AETNA [100010801],,,76.8,,1214.21,354.9345,1340.0556,percent of total billed charges,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,outpatient,,,1136,795.2,AETNA [1000108],AETNA [100010801],,,76.8,,872.45,255.032,962.8736,percent of total billed charges,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,outpatient,,,1269,888.3,AETNA [1000108],AETNA [100010801],,,76.8,,974.59,284.8905,1075.6044,percent of total billed charges,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,outpatient,,,1319,923.3,AETNA [1000108],AETNA [100010801],,,76.8,,1012.99,296.1155,1117.9844,percent of total billed charges,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,outpatient,,,1399,979.3,AETNA [1000108],AETNA [100010801],,,76.8,,1074.43,314.0755,1185.7924,percent of total billed charges,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,outpatient,,,1408,985.6,AETNA [1000108],AETNA [100010801],,,76.8,,1081.34,316.096,1193.4208,percent of total billed charges,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,outpatient,,,2027,1418.9,AETNA [1000108],AETNA [100010801],,,76.8,,1556.74,455.0615,1718.0852,percent of total billed charges,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,outpatient,,,2219,1553.3,AETNA [1000108],AETNA [100010801],,,76.8,,1704.19,498.1655,1880.8244,percent of total billed charges,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,outpatient,,,2602,1821.4,AETNA [1000108],AETNA [100010801],,,76.8,,1998.34,584.149,2205.4552,percent of total billed charges,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,outpatient,,,2943,2060.1,AETNA [1000108],AETNA [100010801],,,76.8,,2260.22,660.7035,2494.4868,percent of total billed charges,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,outpatient,,,5565,3895.5,AETNA [1000108],AETNA [100010801],,,76.8,,4273.92,1249.3425,4716.894,percent of total billed charges,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,outpatient,,,5512,3858.4,AETNA [1000108],AETNA [100010801],,,76.8,,4233.22,1237.444,4671.9712,percent of total billed charges,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,outpatient,,,4120,2884,AETNA [1000108],AETNA [100010801],,,76.8,,3164.16,924.94,3492.112,percent of total billed charges,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,outpatient,,,5512,3858.4,AETNA [1000108],AETNA [100010801],,,76.8,,4233.22,1237.444,4671.9712,percent of total billed charges,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,outpatient,,,1349,944.3,AETNA [1000108],AETNA [100010801],,,76.8,,1036.03,302.8505,1143.4124,percent of total billed charges,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,outpatient,,,39,27.3,AETNA [1000108],AETNA [100010801],,,76.8,,29.95,8.7555,33.0564,percent of total billed charges,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,outpatient,,,1238,866.6,AETNA [1000108],AETNA [100010801],,,76.8,,950.78,277.931,1049.3288,percent of total billed charges,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,outpatient,,,1113,779.1,AETNA [1000108],AETNA [100010801],,,76.8,,854.78,249.8685,943.3788,percent of total billed charges,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,outpatient,,,1887,1320.9,AETNA [1000108],AETNA [100010801],,,76.8,,1449.22,423.6315,1599.4212,percent of total billed charges,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,outpatient,,,1097,767.9,AETNA [1000108],AETNA [100010801],,,76.8,,842.5,246.2765,929.8172,percent of total billed charges,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,outpatient,,,1504,1052.8,AETNA [1000108],AETNA [100010801],,,76.8,,1155.07,337.648,1274.7904,percent of total billed charges,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,outpatient,,,319,223.3,AETNA [1000108],AETNA [100010801],,,76.8,,244.99,71.6155,270.3844,percent of total billed charges,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,outpatient,,,462,323.4,AETNA [1000108],AETNA [100010801],,,76.8,,354.82,103.719,391.5912,percent of total billed charges,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,outpatient,,,1077,753.9,AETNA [1000108],AETNA [100010801],,,76.8,,827.14,241.7865,912.8652,percent of total billed charges,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,outpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,76.8,,373.25,109.107,411.9336,percent of total billed charges,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,outpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,76.8,,343.3,100.3515,378.8772,percent of total billed charges,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,outpatient,,,1332,932.4,AETNA [1000108],AETNA [100010801],,,76.8,,1022.98,299.034,1129.0032,percent of total billed charges,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,outpatient,,,297,207.9,AETNA [1000108],AETNA [100010801],,,76.8,,228.1,66.6765,251.7372,percent of total billed charges,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,outpatient,,,537,375.9,AETNA [1000108],AETNA [100010801],,,76.8,,412.42,120.5565,455.1612,percent of total billed charges,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,outpatient,,,565,395.5,AETNA [1000108],AETNA [100010801],,,76.8,,433.92,126.8425,478.894,percent of total billed charges,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,outpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,76.8,,320.26,93.6165,353.4492,percent of total billed charges,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,outpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,76.8,,316.42,92.494,349.2112,percent of total billed charges,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,outpatient,,,691,483.7,AETNA [1000108],AETNA [100010801],,,76.8,,530.69,155.1295,585.6916,percent of total billed charges,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,outpatient,,,506,354.2,AETNA [1000108],AETNA [100010801],,,76.8,,388.61,113.597,428.8856,percent of total billed charges,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,outpatient,,,424,296.8,AETNA [1000108],AETNA [100010801],,,76.8,,325.63,95.188,359.3824,percent of total billed charges,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,outpatient,,,594,415.8,AETNA [1000108],AETNA [100010801],,,76.8,,456.19,133.353,503.4744,percent of total billed charges,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,outpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,76.8,,406.27,118.7605,448.3804,percent of total billed charges,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,outpatient,,,906,634.2,AETNA [1000108],AETNA [100010801],,,76.8,,695.81,203.397,767.9256,percent of total billed charges,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,outpatient,,,648,453.6,AETNA [1000108],AETNA [100010801],,,76.8,,497.66,145.476,549.2448,percent of total billed charges,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,outpatient,,,990,693,AETNA [1000108],AETNA [100010801],,,76.8,,760.32,222.255,839.124,percent of total billed charges,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,outpatient,,,865,605.5,AETNA [1000108],AETNA [100010801],,,76.8,,664.32,194.1925,733.174,percent of total billed charges,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,outpatient,,,433,303.1,AETNA [1000108],AETNA [100010801],,,76.8,,332.54,97.2085,367.0108,percent of total billed charges,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,outpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,76.8,,302.59,88.453,333.9544,percent of total billed charges,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,outpatient,,,606,424.2,AETNA [1000108],AETNA [100010801],,,76.8,,465.41,136.047,513.6456,percent of total billed charges,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,outpatient,,,700,490,AETNA [1000108],AETNA [100010801],,,76.8,,537.6,157.15,593.32,percent of total billed charges,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,outpatient,,,2205,1543.5,AETNA [1000108],AETNA [100010801],,,76.8,,1693.44,495.0225,1868.958,percent of total billed charges,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,outpatient,,,1336,935.2,AETNA [1000108],AETNA [100010801],,,76.8,,1026.05,299.932,1132.3936,percent of total billed charges,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,outpatient,,,1094,765.8,AETNA [1000108],AETNA [100010801],,,76.8,,840.19,245.603,927.2744,percent of total billed charges,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,outpatient,,,1188,831.6,AETNA [1000108],AETNA [100010801],,,76.8,,912.38,266.706,1006.9488,percent of total billed charges,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,outpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,76.8,,886.27,259.073,978.1304,percent of total billed charges,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,outpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,76.8,,886.27,259.073,978.1304,percent of total billed charges,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,outpatient,,,785,549.5,AETNA [1000108],AETNA [100010801],,,76.8,,602.88,176.2325,665.366,percent of total billed charges,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,outpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,76.8,,598.27,174.8855,660.2804,percent of total billed charges,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,outpatient,,,1191,833.7,AETNA [1000108],AETNA [100010801],,,76.8,,914.69,267.3795,1009.4916,percent of total billed charges,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,outpatient,,,983,688.1,AETNA [1000108],AETNA [100010801],,,76.8,,754.94,220.6835,833.1908,percent of total billed charges,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,outpatient,,,457,319.9,AETNA [1000108],AETNA [100010801],,,76.8,,350.98,102.5965,387.3532,percent of total billed charges,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,outpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,76.8,,361.73,105.7395,399.2196,percent of total billed charges,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,outpatient,,,465,325.5,AETNA [1000108],AETNA [100010801],,,76.8,,357.12,104.3925,394.134,percent of total billed charges,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,outpatient,,,823,576.1,AETNA [1000108],AETNA [100010801],,,76.8,,632.06,184.7635,697.5748,percent of total billed charges,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,outpatient,,,619,433.3,AETNA [1000108],AETNA [100010801],,,76.8,,475.39,138.9655,524.6644,percent of total billed charges,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,outpatient,,,795,556.5,AETNA [1000108],AETNA [100010801],,,76.8,,610.56,178.4775,673.842,percent of total billed charges,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,outpatient,,,722,505.4,AETNA [1000108],AETNA [100010801],,,76.8,,554.5,162.089,611.9672,percent of total billed charges,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,outpatient,,,245,171.5,AETNA [1000108],AETNA [100010801],,,76.8,,188.16,55.0025,207.662,percent of total billed charges,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,outpatient,,,954,667.8,AETNA [1000108],AETNA [100010801],,,76.8,,732.67,214.173,808.6104,percent of total billed charges,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,outpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,76.8,,886.27,259.073,978.1304,percent of total billed charges,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,outpatient,,,497,347.9,AETNA [1000108],AETNA [100010801],,,76.8,,381.7,111.5765,421.2572,percent of total billed charges,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,outpatient,,,251,175.7,AETNA [1000108],AETNA [100010801],,,76.8,,192.77,56.3495,212.7476,percent of total billed charges,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,outpatient,,,408,285.6,AETNA [1000108],AETNA [100010801],,,76.8,,313.34,91.596,345.8208,percent of total billed charges,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,outpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,76.8,,343.3,100.3515,378.8772,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,outpatient,,,359,251.3,AETNA [1000108],AETNA [100010801],,,76.8,,275.71,80.5955,304.2884,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,outpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,76.8,,239.62,70.044,264.4512,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,outpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,76.8,,239.62,70.044,264.4512,percent of total billed charges,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,outpatient,,,622,435.4,AETNA [1000108],AETNA [100010801],,,76.8,,477.7,139.639,527.2072,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,outpatient,,,552,386.4,AETNA [1000108],AETNA [100010801],,,76.8,,423.94,123.924,467.8752,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,outpatient,,,1221,854.7,AETNA [1000108],AETNA [100010801],,,76.8,,937.73,274.1145,1034.9196,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,outpatient,,,3772,2640.4,AETNA [1000108],AETNA [100010801],,,76.8,,2896.9,846.814,3197.1472,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,outpatient,,,1954,1367.8,AETNA [1000108],AETNA [100010801],,,76.8,,1500.67,438.673,1656.2104,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,outpatient,,,3806,2664.2,AETNA [1000108],AETNA [100010801],,,76.8,,2923.01,854.447,3225.9656,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,outpatient,,,661,462.7,AETNA [1000108],AETNA [100010801],,,76.8,,507.65,148.3945,560.2636,percent of total billed charges,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,outpatient,,,570,399,AETNA [1000108],AETNA [100010801],,,76.8,,437.76,127.965,483.132,percent of total billed charges,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,outpatient,,,570,399,AETNA [1000108],AETNA [100010801],,,76.8,,437.76,127.965,483.132,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,outpatient,,,3385,2369.5,AETNA [1000108],AETNA [100010801],,,76.8,,2599.68,759.9325,2869.126,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,outpatient,,,3185,2229.5,AETNA [1000108],AETNA [100010801],,,76.8,,2446.08,715.0325,2699.606,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,outpatient,,,380,266,AETNA [1000108],AETNA [100010801],,,76.8,,291.84,85.31,322.088,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,outpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,76.8,,598.27,174.8855,660.2804,percent of total billed charges,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,outpatient,,,330,231,AETNA [1000108],AETNA [100010801],,,76.8,,253.44,74.085,279.708,percent of total billed charges,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,outpatient,,,382,267.4,AETNA [1000108],AETNA [100010801],,,76.8,,293.38,85.759,323.7832,percent of total billed charges,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,outpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,76.8,,344.06,100.576,379.7248,percent of total billed charges,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,outpatient,,,473,331.1,AETNA [1000108],AETNA [100010801],,,76.8,,363.26,106.1885,400.9148,percent of total billed charges,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,112.699,425.4952,percent of total billed charges,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,557.7208,percent of total billed charges,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,outpatient,,,661,462.7,AETNA [1000108],AETNA [100010801],,,76.8,,507.65,148.3945,560.2636,percent of total billed charges,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,outpatient,,,703,492.1,AETNA [1000108],AETNA [100010801],,,76.8,,539.9,157.8235,595.8628,percent of total billed charges,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,outpatient,,,745,521.5,AETNA [1000108],AETNA [100010801],,,76.8,,572.16,167.2525,631.462,percent of total billed charges,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,outpatient,,,785,549.5,AETNA [1000108],AETNA [100010801],,,76.8,,602.88,176.2325,665.366,percent of total billed charges,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,outpatient,,,901,630.7,AETNA [1000108],AETNA [100010801],,,76.8,,691.97,202.2745,763.6876,percent of total billed charges,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,775.554,percent of total billed charges,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,outpatient,,,1117,781.9,AETNA [1000108],AETNA [100010801],,,76.8,,857.86,250.7665,946.7692,percent of total billed charges,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,outpatient,,,2560,1792,AETNA [1000108],AETNA [100010801],,,76.8,,1966.08,574.72,2169.856,percent of total billed charges,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,outpatient,,,2560,1792,AETNA [1000108],AETNA [100010801],,,76.8,,1966.08,574.72,2169.856,percent of total billed charges,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,667.663,2520.7624,percent of total billed charges,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,outpatient,,,3011,2107.7,AETNA [1000108],AETNA [100010801],,,76.8,,2312.45,675.9695,2552.1236,percent of total billed charges,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,outpatient,,,3011,2107.7,AETNA [1000108],AETNA [100010801],,,76.8,,2312.45,675.9695,2552.1236,percent of total billed charges,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,outpatient,,,3165,2215.5,AETNA [1000108],AETNA [100010801],,,76.8,,2430.72,710.5425,2682.654,percent of total billed charges,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,outpatient,,,3418,2392.6,AETNA [1000108],AETNA [100010801],,,76.8,,2625.02,767.341,2897.0968,percent of total billed charges,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,outpatient,,,3462,2423.4,AETNA [1000108],AETNA [100010801],,,76.8,,2658.82,777.219,2934.3912,percent of total billed charges,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,outpatient,,,6597,4617.9,AETNA [1000108],AETNA [100010801],,,76.8,,5066.5,1481.0265,5591.6172,percent of total billed charges,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,557.7208,percent of total billed charges,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,557.7208,percent of total billed charges,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,outpatient,,,1232,862.4,AETNA [1000108],AETNA [100010801],,,76.8,,946.18,276.584,1044.2432,percent of total billed charges,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,outpatient,,,1750,1225,AETNA [1000108],AETNA [100010801],,,76.8,,1344,392.875,1483.3,percent of total billed charges,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,outpatient,,,3933,2753.1,AETNA [1000108],AETNA [100010801],,,76.8,,3020.54,882.9585,3333.6108,percent of total billed charges,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,outpatient,,,4114,2879.8,AETNA [1000108],AETNA [100010801],,,76.8,,3159.55,923.593,3487.0264,percent of total billed charges,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,outpatient,,,4461,3122.7,AETNA [1000108],AETNA [100010801],,,76.8,,3426.05,1001.4945,3781.1436,percent of total billed charges,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,104.617,394.9816,percent of total billed charges,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,667.663,2520.7624,percent of total billed charges,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,667.663,2520.7624,percent of total billed charges,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,667.663,2520.7624,percent of total billed charges,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,outpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,76.8,,815.62,238.419,900.1512,percent of total billed charges,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,outpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,76.8,,815.62,238.419,900.1512,percent of total billed charges,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,outpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,76.8,,815.62,238.419,900.1512,percent of total billed charges,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,outpatient,,,1445,1011.5,AETNA [1000108],AETNA [100010801],,,76.8,,1109.76,324.4025,1224.782,percent of total billed charges,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,outpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,76.8,,344.06,100.576,379.7248,percent of total billed charges,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,77.9015,294.1172,percent of total billed charges,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,outpatient,,,1065,745.5,AETNA [1000108],AETNA [100010801],,,76.8,,817.92,239.0925,902.694,percent of total billed charges,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,outpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,76.8,,271.1,79.2485,299.2028,percent of total billed charges,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,outpatient,,,1413,989.1,AETNA [1000108],AETNA [100010801],,,76.8,,1085.18,317.2185,1197.6588,percent of total billed charges,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,outpatient,,,1290,903,AETNA [1000108],AETNA [100010801],,,76.8,,990.72,289.605,1093.404,percent of total billed charges,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,outpatient,,,1290,903,AETNA [1000108],AETNA [100010801],,,76.8,,990.72,289.605,1093.404,percent of total billed charges,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,outpatient,,,2135,1494.5,AETNA [1000108],AETNA [100010801],,,76.8,,1639.68,479.3075,1809.626,percent of total billed charges,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,outpatient,,,745,521.5,AETNA [1000108],AETNA [100010801],,,76.8,,572.16,167.2525,631.462,percent of total billed charges,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,222.0712,percent of total billed charges,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,222.0712,percent of total billed charges,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,outpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,76.8,,271.1,79.2485,299.2028,percent of total billed charges,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,outpatient,,,1286,900.2,AETNA [1000108],AETNA [100010801],,,76.8,,987.65,288.707,1090.0136,percent of total billed charges,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,outpatient,,,649,454.3,AETNA [1000108],AETNA [100010801],,,76.8,,498.43,145.7005,550.0924,percent of total billed charges,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,outpatient,,,758,530.6,AETNA [1000108],AETNA [100010801],,,76.8,,582.14,170.171,642.4808,percent of total billed charges,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,outpatient,,,1063,744.1,AETNA [1000108],AETNA [100010801],,,76.8,,816.38,238.6435,900.9988,percent of total billed charges,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,outpatient,,,1093,765.1,AETNA [1000108],AETNA [100010801],,,76.8,,839.42,245.3785,926.4268,percent of total billed charges,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,outpatient,,,1217,851.9,AETNA [1000108],AETNA [100010801],,,76.8,,934.66,273.2165,1031.5292,percent of total billed charges,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,outpatient,,,1355,948.5,AETNA [1000108],AETNA [100010801],,,76.8,,1040.64,304.1975,1148.498,percent of total billed charges,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,outpatient,,,1398,978.6,AETNA [1000108],AETNA [100010801],,,76.8,,1073.66,313.851,1184.9448,percent of total billed charges,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,outpatient,,,1474,1031.8,AETNA [1000108],AETNA [100010801],,,76.8,,1132.03,330.913,1249.3624,percent of total billed charges,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,outpatient,,,1499,1049.3,AETNA [1000108],AETNA [100010801],,,76.8,,1151.23,336.5255,1270.5524,percent of total billed charges,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,outpatient,,,1773,1241.1,AETNA [1000108],AETNA [100010801],,,76.8,,1361.66,398.0385,1502.7948,percent of total billed charges,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,outpatient,,,1585,1109.5,AETNA [1000108],AETNA [100010801],,,76.8,,1217.28,355.8325,1343.446,percent of total billed charges,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,outpatient,,,1636,1145.2,AETNA [1000108],AETNA [100010801],,,76.8,,1256.45,367.282,1386.6736,percent of total billed charges,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,outpatient,,,1749,1224.3,AETNA [1000108],AETNA [100010801],,,76.8,,1343.23,392.6505,1482.4524,percent of total billed charges,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,outpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,76.8,,364.03,106.413,401.7624,percent of total billed charges,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,outpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,76.8,,364.03,106.413,401.7624,percent of total billed charges,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,outpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,76.8,,364.03,106.413,401.7624,percent of total billed charges,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,outpatient,,,328,229.6,AETNA [1000108],AETNA [100010801],,,76.8,,251.9,73.636,278.0128,percent of total billed charges,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,outpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,76.8,,373.25,109.107,411.9336,percent of total billed charges,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,outpatient,,,1773,1241.1,AETNA [1000108],AETNA [100010801],,,76.8,,1361.66,398.0385,1502.7948,percent of total billed charges,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,outpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,76.8,,532.99,155.803,588.2344,percent of total billed charges,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,outpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,76.8,,364.03,106.413,401.7624,percent of total billed charges,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,outpatient,,,475,332.5,AETNA [1000108],AETNA [100010801],,,76.8,,364.8,106.6375,402.61,percent of total billed charges,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,outpatient,,,1710,1197,AETNA [1000108],AETNA [100010801],,,76.8,,1313.28,383.895,1449.396,percent of total billed charges,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,outpatient,,,1327,928.9,AETNA [1000108],AETNA [100010801],,,76.8,,1019.14,297.9115,1124.7652,percent of total billed charges,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,outpatient,,,1327,928.9,AETNA [1000108],AETNA [100010801],,,76.8,,1019.14,297.9115,1124.7652,percent of total billed charges,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,outpatient,,,1300,910,AETNA [1000108],AETNA [100010801],,,76.8,,998.4,291.85,1101.88,percent of total billed charges,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,outpatient,,,32,22.4,AETNA [1000108],AETNA [100010801],,,76.8,,24.58,7.184,27.1232,percent of total billed charges,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,outpatient,,,142,99.4,AETNA [1000108],AETNA [100010801],,,76.8,,109.06,31.879,120.3592,percent of total billed charges,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,outpatient,,,157,109.9,AETNA [1000108],AETNA [100010801],,,76.8,,120.58,35.2465,133.0732,percent of total billed charges,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,outpatient,,,152,106.4,AETNA [1000108],AETNA [100010801],,,76.8,,116.74,34.124,128.8352,percent of total billed charges,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,outpatient,,,208,145.6,AETNA [1000108],AETNA [100010801],,,76.8,,159.74,46.696,176.3008,percent of total billed charges,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,outpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,76.8,,46.08,13.47,50.856,percent of total billed charges,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,outpatient,,,75,52.5,AETNA [1000108],AETNA [100010801],,,76.8,,57.6,16.8375,63.57,percent of total billed charges,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,outpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,76.8,,46.08,13.47,50.856,percent of total billed charges,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,outpatient,,,75,52.5,AETNA [1000108],AETNA [100010801],,,76.8,,57.6,16.8375,63.57,percent of total billed charges,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,outpatient,,,99,69.3,AETNA [1000108],AETNA [100010801],,,76.8,,76.03,22.2255,83.9124,percent of total billed charges,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,outpatient,,,140,98,AETNA [1000108],AETNA [100010801],,,76.8,,107.52,31.43,118.664,percent of total billed charges,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,outpatient,,,138,96.6,AETNA [1000108],AETNA [100010801],,,76.8,,105.98,30.981,116.9688,percent of total billed charges,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,35.6955,134.7684,percent of total billed charges,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,outpatient,,,700,490,AETNA [1000108],AETNA [100010801],,,76.8,,537.6,157.15,593.32,percent of total billed charges,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,outpatient,,,850,595,AETNA [1000108],AETNA [100010801],,,76.8,,652.8,190.825,720.46,percent of total billed charges,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,outpatient,,,1662,1163.4,AETNA [1000108],AETNA [100010801],,,76.8,,1276.42,373.119,1408.7112,percent of total billed charges,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,76.8,,729.6,213.275,805.22,percent of total billed charges,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,outpatient,,,2924,2046.8,AETNA [1000108],AETNA [100010801],,,76.8,,2245.63,656.438,2478.3824,percent of total billed charges,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,outpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,76.8,,921.6,269.4,1017.12,percent of total billed charges,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,outpatient,,,4262,2983.4,AETNA [1000108],AETNA [100010801],,,76.8,,3273.22,956.819,3612.4712,percent of total billed charges,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,outpatient,,,9166,6416.2,AETNA [1000108],AETNA [100010801],,,76.8,,7039.49,2057.767,7769.1016,percent of total billed charges,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,outpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,76.8,,921.6,269.4,1017.12,percent of total billed charges,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,outpatient,,,3749,2624.3,AETNA [1000108],AETNA [100010801],,,76.8,,2879.23,841.6505,3177.6524,percent of total billed charges,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,outpatient,,,5356,3749.2,AETNA [1000108],AETNA [100010801],,,76.8,,4113.41,1202.422,4539.7456,percent of total billed charges,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,outpatient,,,9641,6748.7,AETNA [1000108],AETNA [100010801],,,76.8,,7404.29,2164.4045,8171.7116,percent of total billed charges,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,outpatient,,,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,5.6125,21.19,percent of total billed charges,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,outpatient,,,22,15.4,AETNA [1000108],AETNA [100010801],,,76.8,,16.9,4.939,18.6472,percent of total billed charges,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,outpatient,,,23,16.1,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,5.1635,19.4948,percent of total billed charges,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,outpatient,,,28,19.6,AETNA [1000108],AETNA [100010801],,,76.8,,21.5,6.286,23.7328,percent of total billed charges,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,outpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,76.8,,22.27,6.5105,24.5804,percent of total billed charges,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,outpatient,,,33,23.1,AETNA [1000108],AETNA [100010801],,,76.8,,25.34,7.4085,27.9708,percent of total billed charges,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,outpatient,,,38,26.6,AETNA [1000108],AETNA [100010801],,,76.8,,29.18,8.531,32.2088,percent of total billed charges,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,outpatient,,,1500,1050,AETNA [1000108],AETNA [100010801],,,76.8,,1152,336.75,1271.4,percent of total billed charges,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,outpatient,,,101,70.7,AETNA [1000108],AETNA [100010801],,,76.8,,77.57,22.6745,6652,percent of total billed charges,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,outpatient,,,569,398.3,AETNA [1000108],AETNA [100010801],,,76.8,,436.99,127.7405,482.2844,percent of total billed charges,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,outpatient,,,569,398.3,AETNA [1000108],AETNA [100010801],,,76.8,,436.99,127.7405,482.2844,percent of total billed charges,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,outpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,76.8,,22.27,6.5105,24.5804,percent of total billed charges,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,outpatient,,,7,4.9,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,1.5715,163,percent of total billed charges,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,outpatient,,,43,30.1,AETNA [1000108],AETNA [100010801],,,76.8,,33.02,9.6535,163,percent of total billed charges,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,outpatient,,,171,119.7,AETNA [1000108],AETNA [100010801],,,76.8,,131.33,38.3895,163,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,AETNA [1000108],AETNA [100010801],,,76.8,,594.43,173.763,2998,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,AETNA [1000108],AETNA [100010801],,,76.8,,123.65,36.1445,2998,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,22389.354,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,AETNA [1000108],AETNA [100010801],,,76.8,,564.48,165.0075,2998,percent of total billed charges,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,AETNA [1000108],AETNA [100010801],,,76.8,,1477.69,0.1,1477.69344,percent of total billed charges,
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,AETNA [1000108],AETNA [100010801],,,76.8,,35.27,10.30904,416.02,percent of total billed charges,
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,AETNA [1000108],AETNA [100010801],,,76.8,,13.17,3.850175,416.02,percent of total billed charges,
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,AETNA [1000108],AETNA [100010801],,,76.8,,30.07,4.025285,416.02,percent of total billed charges,
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,AETNA [1000108],AETNA [100010801],,,76.8,,32.13,4.025285,416.02,percent of total billed charges,
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,AETNA [1000108],AETNA [100010801],,,76.8,,13.77,4.025285,416.02,percent of total billed charges,
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,AETNA [1000108],AETNA [100010801],,,76.8,,32.13,4.025285,416.02,percent of total billed charges,
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA [1000108],AETNA [100010801],,,76.8,,19.54,2.98585,416.02,percent of total billed charges,
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA [1000108],AETNA [100010801],,,76.8,,19.54,2.98585,416.02,percent of total billed charges,
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA [1000108],AETNA [100010801],,,76.8,,19.54,2.98585,416.02,percent of total billed charges,
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA [1000108],AETNA [100010801],,,76.8,,19.54,2.98585,416.02,percent of total billed charges,
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,AETNA [1000108],AETNA [100010801],,,76.8,,10.21,2.98585,416.02,percent of total billed charges,
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,76.8,,321.02,39.325665,1791.14496,percent of total billed charges,
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,AETNA [1000108],AETNA [100010801],,,76.8,,208.38,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,AETNA [1000108],AETNA [100010801],,,76.8,,842.65,39.325665,1791.14496,percent of total billed charges,
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,AETNA [1000108],AETNA [100010801],,,76.8,,382.07,39.325665,1791.14496,percent of total billed charges,
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA [1000108],AETNA [100010801],,,76.8,,134.53,39.325665,1791.14496,percent of total billed charges,
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA [1000108],AETNA [100010801],,,76.8,,134.53,39.325665,1791.14496,percent of total billed charges,
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA [1000108],AETNA [100010801],,,76.8,,134.53,39.325665,1791.14496,percent of total billed charges,
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,AETNA [1000108],AETNA [100010801],,,76.8,,578.09,39.325665,1791.14496,percent of total billed charges,
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,AETNA [1000108],AETNA [100010801],,,76.8,,867.08,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA [1000108],AETNA [100010801],,,76.8,,369.48,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.325665,1791.14496,percent of total billed charges,
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.325665,1791.14496,percent of total billed charges,
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.325665,1791.14496,percent of total billed charges,
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.325665,1791.14496,percent of total billed charges,
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,AETNA [1000108],AETNA [100010801],,,76.8,,285.68,39.325665,1791.14496,percent of total billed charges,
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,AETNA [1000108],AETNA [100010801],,,76.8,,3829.79,14.186155,5948.3904,percent of total billed charges,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,AETNA [1000108],AETNA [100010801],,,76.8,,4533.81,14.186155,5948.3904,percent of total billed charges,
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,76.8,,4057.94,14.186155,5948.3904,percent of total billed charges,
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,AETNA [1000108],AETNA [100010801],,,76.8,,48.53,14.186155,5948.3904,percent of total billed charges,
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,14.186155,5948.3904,percent of total billed charges,
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,AETNA [1000108],AETNA [100010801],,,76.8,,5948.39,14.186155,5948.3904,percent of total billed charges,
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,AETNA [1000108],AETNA [100010801],,,76.8,,5948.39,14.186155,5948.3904,percent of total billed charges,
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,AETNA [1000108],AETNA [100010801],,,76.8,,4481.66,14.186155,5948.3904,percent of total billed charges,
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,AETNA [1000108],AETNA [100010801],,,76.8,,3829.79,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,AETNA [1000108],AETNA [100010801],,,76.8,,25.32,7.401765,416.02,percent of total billed charges,
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,AETNA [1000108],AETNA [100010801],,,76.8,,33.34,7.401765,416.02,percent of total billed charges,
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,AETNA [1000108],AETNA [100010801],,,76.8,,138.35,11.99,416.02,percent of total billed charges,
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,AETNA [1000108],AETNA [100010801],,,76.8,,11.09,1.708445,416.02,percent of total billed charges,
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,AETNA [1000108],AETNA [100010801],,,76.8,,6.65,1.708445,416.02,percent of total billed charges,
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,1.708445,416.02,percent of total billed charges,
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,AETNA [1000108],AETNA [100010801],,,76.8,,10.93,1.708445,416.02,percent of total billed charges,
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,AETNA [1000108],AETNA [100010801],,,76.8,,15.41,1.708445,416.02,percent of total billed charges,
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,AETNA [1000108],AETNA [100010801],,,76.8,,14.11,1.708445,416.02,percent of total billed charges,
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,AETNA [1000108],AETNA [100010801],,,76.8,,13.92,4.070185,416.02,percent of total billed charges,
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,AETNA [1000108],AETNA [100010801],,,76.8,,13.92,4.070185,416.02,percent of total billed charges,
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,AETNA [1000108],AETNA [100010801],,,76.8,,21.31,4.070185,416.02,percent of total billed charges,
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,AETNA [1000108],AETNA [100010801],,,76.8,,86.36,4.070185,416.02,percent of total billed charges,
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,AETNA [1000108],AETNA [100010801],,,76.8,,26.66,4.070185,416.02,percent of total billed charges,
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,AETNA [1000108],AETNA [100010801],,,76.8,,26.32,4.070185,416.02,percent of total billed charges,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,4.3553,416.02,percent of total billed charges,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,AETNA [1000108],AETNA [100010801],,,76.8,,14.9,4.3553,416.02,percent of total billed charges,
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,AETNA [1000108],AETNA [100010801],,,76.8,,46.03,4.3553,416.02,percent of total billed charges,
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,AETNA [1000108],AETNA [100010801],,,76.8,,130.41,5.23,416.02,percent of total billed charges,
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,AETNA [1000108],AETNA [100010801],,,76.8,,62.36,9.98576,416.02,percent of total billed charges,
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,AETNA [1000108],AETNA [100010801],,,76.8,,34.16,9.98576,416.02,percent of total billed charges,
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,AETNA [1000108],AETNA [100010801],,,76.8,,11.24,2.94544,416.02,percent of total billed charges,
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,AETNA [1000108],AETNA [100010801],,,76.8,,10.08,2.94544,416.02,percent of total billed charges,
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,AETNA [1000108],AETNA [100010801],,,76.8,,205.92,2.94544,416.02,percent of total billed charges,
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,AETNA [1000108],AETNA [100010801],,,76.8,,20.57,2.94544,416.02,percent of total billed charges,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,AETNA [1000108],AETNA [100010801],,,76.8,,31.2,9.121435,416.02,percent of total billed charges,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,AETNA [1000108],AETNA [100010801],,,76.8,,319.87,9.121435,416.02,percent of total billed charges,
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,AETNA [1000108],AETNA [100010801],,,76.8,,70.79,20.692165,416.02,percent of total billed charges,
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,AETNA [1000108],AETNA [100010801],,,76.8,,114.41,9.206745,416.02,percent of total billed charges,
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,AETNA [1000108],AETNA [100010801],,,76.8,,31.5,9.206745,416.02,percent of total billed charges,
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,AETNA [1000108],AETNA [100010801],,,,,,0.04041,416.02,other,Supplies A-Codes
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,AETNA [1000108],AETNA [100010801],,,,,,0.04041,416.02,other,Supplies A-Codes
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,AETNA [1000108],AETNA [100010801],,,,,,0.04041,416.02,other,Supplies A-Codes
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,AETNA [1000108],AETNA [100010801],,,,,,0.04041,416.02,other,Supplies A-Codes
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,AETNA [1000108],AETNA [100010801],,,76.8,,3.13,0.913715,416.02,percent of total billed charges,
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,AETNA [1000108],AETNA [100010801],,,76.8,,5.15,0.913715,416.02,percent of total billed charges,
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,AETNA [1000108],AETNA [100010801],,,76.8,,3.45,0.913715,416.02,percent of total billed charges,
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,AETNA [1000108],AETNA [100010801],,,76.8,,5.17,0.913715,416.02,percent of total billed charges,
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,AETNA [1000108],AETNA [100010801],,,76.8,,9.15,2.67604,416.02,percent of total billed charges,
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,AETNA [1000108],AETNA [100010801],,,76.8,,7.4,1.659055,416.02,percent of total billed charges,
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,AETNA [1000108],AETNA [100010801],,,76.8,,8.53,1.659055,416.02,percent of total billed charges,
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,AETNA [1000108],AETNA [100010801],,,76.8,,5.68,1.659055,416.02,percent of total billed charges,
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,AETNA [1000108],AETNA [100010801],,,76.8,,32.81,4.600005,416.02,percent of total billed charges,
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,AETNA [1000108],AETNA [100010801],,,76.8,,15.74,4.600005,416.02,percent of total billed charges,
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,AETNA [1000108],AETNA [100010801],,,76.8,,16.73,4.600005,416.02,percent of total billed charges,
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,AETNA [1000108],AETNA [100010801],,,76.8,,24.25,7.087465,416.02,percent of total billed charges,
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,AETNA [1000108],AETNA [100010801],,,76.8,,12.55,3.66833,416.02,percent of total billed charges,
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,3.66833,416.02,percent of total billed charges,
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,3.122795,416.02,percent of total billed charges,
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,AETNA [1000108],AETNA [100010801],,,76.8,,26.14,3.122795,416.02,percent of total billed charges,
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,AETNA [1000108],AETNA [100010801],,,76.8,,6.77,1.98009,416.02,percent of total billed charges,
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.75881,416.02,percent of total billed charges,
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.75881,416.02,percent of total billed charges,
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,AETNA [1000108],AETNA [100010801],,,76.8,,2.71,0.75881,416.02,percent of total billed charges,
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,AETNA [1000108],AETNA [100010801],,,76.8,,5.35,0.75881,416.02,percent of total billed charges,
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,AETNA [1000108],AETNA [100010801],,,76.8,,8.13,0.75881,416.02,percent of total billed charges,
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA [1000108],AETNA [100010801],,,76.8,,7.57,2.21357,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,AETNA [1000108],AETNA [100010801],,,76.8,,78.72,4.17,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,AETNA [1000108],AETNA [100010801],,,76.8,,77.24,4.17,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,AETNA [1000108],AETNA [100010801],,,76.8,,77.23,4.17,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,AETNA [1000108],AETNA [100010801],,,76.8,,77.23,4.17,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,AETNA [1000108],AETNA [100010801],,,76.8,,77.23,4.17,416.02,percent of total billed charges,
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,AETNA [1000108],AETNA [100010801],,,76.8,,104.64,0.12,416.02,percent of total billed charges,
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA [1000108],AETNA [100010801],,,76.8,,2961.38,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,AETNA [1000108],AETNA [100010801],,,76.8,,1600.02,0.518595,35041.66656,percent of total billed charges,
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,AETNA [1000108],AETNA [100010801],,,76.8,,565,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,AETNA [1000108],AETNA [100010801],,,76.8,,2881.81,0.518595,35041.66656,percent of total billed charges,
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,AETNA [1000108],AETNA [100010801],,,76.8,,4822.27,0.518595,35041.66656,percent of total billed charges,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,76.8,,304.73,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,AETNA [1000108],AETNA [100010801],,,76.8,,7235.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA [1000108],AETNA [100010801],,,76.8,,872.66,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA [1000108],AETNA [100010801],,,76.8,,872.66,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA [1000108],AETNA [100010801],,,76.8,,872.66,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,AETNA [1000108],AETNA [100010801],,,76.8,,54.51,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,AETNA [1000108],AETNA [100010801],,,76.8,,113,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,AETNA [1000108],AETNA [100010801],,,76.8,,112.93,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,AETNA [1000108],AETNA [100010801],,,76.8,,54.49,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA [1000108],AETNA [100010801],,,76.8,,186.11,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA [1000108],AETNA [100010801],,,76.8,,186.11,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA [1000108],AETNA [100010801],,,76.8,,186.11,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA [1000108],AETNA [100010801],,,76.8,,186.11,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,AETNA [1000108],AETNA [100010801],,,76.8,,119.64,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,AETNA [1000108],AETNA [100010801],,,76.8,,119.61,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,AETNA [1000108],AETNA [100010801],,,76.8,,1074.69,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,AETNA [1000108],AETNA [100010801],,,76.8,,1645.33,0.518595,35041.66656,percent of total billed charges,
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,AETNA [1000108],AETNA [100010801],,,76.8,,1645.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,AETNA [1000108],AETNA [100010801],,,76.8,,1962.28,0.518595,35041.66656,percent of total billed charges,
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,AETNA [1000108],AETNA [100010801],,,76.8,,1962.28,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,AETNA [1000108],AETNA [100010801],,,76.8,,89.73,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,AETNA [1000108],AETNA [100010801],,,76.8,,1343.44,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,AETNA [1000108],AETNA [100010801],,,76.8,,996.24,0.518595,35041.66656,percent of total billed charges,
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,AETNA [1000108],AETNA [100010801],,,76.8,,10830.31,0.518595,35041.66656,percent of total billed charges,
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,AETNA [1000108],AETNA [100010801],,,76.8,,4519.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,AETNA [1000108],AETNA [100010801],,,76.8,,5511.14,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,AETNA [1000108],AETNA [100010801],,,76.8,,465.29,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,AETNA [1000108],AETNA [100010801],,,76.8,,465.29,0.518595,35041.66656,percent of total billed charges,
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,AETNA [1000108],AETNA [100010801],,,76.8,,714.54,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA [1000108],AETNA [100010801],,,76.8,,598.2,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA [1000108],AETNA [100010801],,,76.8,,598.2,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA [1000108],AETNA [100010801],,,76.8,,598.2,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,AETNA [1000108],AETNA [100010801],,,76.8,,565,0.518595,35041.66656,percent of total billed charges,
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,AETNA [1000108],AETNA [100010801],,,76.8,,4592.62,0.518595,35041.66656,percent of total billed charges,
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,AETNA [1000108],AETNA [100010801],,,76.8,,225.99,0.518595,35041.66656,percent of total billed charges,
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,AETNA [1000108],AETNA [100010801],,,76.8,,7338.16,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,AETNA [1000108],AETNA [100010801],,,76.8,,1841.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,AETNA [1000108],AETNA [100010801],,,76.8,,3344.41,0.518595,35041.66656,percent of total billed charges,
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,AETNA [1000108],AETNA [100010801],,,76.8,,1147.18,0.518595,35041.66656,percent of total billed charges,
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,AETNA [1000108],AETNA [100010801],,,76.8,,1600.02,0.518595,35041.66656,percent of total billed charges,
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,AETNA [1000108],AETNA [100010801],,,76.8,,1373.61,0.518595,35041.66656,percent of total billed charges,
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,AETNA [1000108],AETNA [100010801],,,76.8,,2080.07,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,AETNA [1000108],AETNA [100010801],,,76.8,,2936.56,0.518595,35041.66656,percent of total billed charges,
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,AETNA [1000108],AETNA [100010801],,,76.8,,2542.3,0.518595,35041.66656,percent of total billed charges,
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,AETNA [1000108],AETNA [100010801],,,76.8,,2719.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,AETNA [1000108],AETNA [100010801],,,76.8,,4906.85,0.518595,35041.66656,percent of total billed charges,
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,AETNA [1000108],AETNA [100010801],,,76.8,,3208.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,AETNA [1000108],AETNA [100010801],,,76.8,,2909.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,AETNA [1000108],AETNA [100010801],,,76.8,,252.61,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,AETNA [1000108],AETNA [100010801],,,76.8,,581.58,0.518595,35041.66656,percent of total billed charges,
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,AETNA [1000108],AETNA [100010801],,,76.8,,581.58,0.518595,35041.66656,percent of total billed charges,
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,76.8,,291.29,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,AETNA [1000108],AETNA [100010801],,,76.8,,99,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,AETNA [1000108],AETNA [100010801],,,76.8,,113.15,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA [1000108],AETNA [100010801],,,76.8,,149.58,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA [1000108],AETNA [100010801],,,76.8,,149.58,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA [1000108],AETNA [100010801],,,76.8,,149.58,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,AETNA [1000108],AETNA [100010801],,,76.8,,159.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,AETNA [1000108],AETNA [100010801],,,76.8,,296.89,0.518595,35041.66656,percent of total billed charges,
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,AETNA [1000108],AETNA [100010801],,,76.8,,299.13,0.518595,35041.66656,percent of total billed charges,
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,AETNA [1000108],AETNA [100010801],,,76.8,,279.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,AETNA [1000108],AETNA [100010801],,,76.8,,332.33,0.518595,35041.66656,percent of total billed charges,
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,AETNA [1000108],AETNA [100010801],,,76.8,,1147.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,AETNA [1000108],AETNA [100010801],,,76.8,,312.44,0.518595,35041.66656,percent of total billed charges,
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,AETNA [1000108],AETNA [100010801],,,76.8,,614.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,AETNA [1000108],AETNA [100010801],,,76.8,,325.7,0.518595,35041.66656,percent of total billed charges,
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,AETNA [1000108],AETNA [100010801],,,76.8,,631.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,AETNA [1000108],AETNA [100010801],,,76.8,,325.7,0.518595,35041.66656,percent of total billed charges,
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,AETNA [1000108],AETNA [100010801],,,76.8,,348.96,0.518595,35041.66656,percent of total billed charges,
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,AETNA [1000108],AETNA [100010801],,,76.8,,681.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,AETNA [1000108],AETNA [100010801],,,76.8,,697.91,0.518595,35041.66656,percent of total billed charges,
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,AETNA [1000108],AETNA [100010801],,,76.8,,845.3,0.518595,35041.66656,percent of total billed charges,
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,AETNA [1000108],AETNA [100010801],,,76.8,,548.38,0.518595,35041.66656,percent of total billed charges,
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,AETNA [1000108],AETNA [100010801],,,76.8,,731.17,0.518595,35041.66656,percent of total billed charges,
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,AETNA [1000108],AETNA [100010801],,,76.8,,780.99,0.518595,35041.66656,percent of total billed charges,
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,AETNA [1000108],AETNA [100010801],,,76.8,,814.25,0.518595,35041.66656,percent of total billed charges,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,AETNA [1000108],AETNA [100010801],,,76.8,,1433.97,0.518595,35041.66656,percent of total billed charges,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,AETNA [1000108],AETNA [100010801],,,76.8,,1971.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,AETNA [1000108],AETNA [100010801],,,76.8,,830.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,AETNA [1000108],AETNA [100010801],,,76.8,,1011.35,0.518595,35041.66656,percent of total billed charges,
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,AETNA [1000108],AETNA [100010801],,,76.8,,1041.55,0.518595,35041.66656,percent of total billed charges,
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,76.8,,622.9,0.518595,35041.66656,percent of total billed charges,
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,AETNA [1000108],AETNA [100010801],,,76.8,,695.05,0.518595,35041.66656,percent of total billed charges,
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,AETNA [1000108],AETNA [100010801],,,76.8,,38.32,0.518595,35041.66656,percent of total billed charges,
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,AETNA [1000108],AETNA [100010801],,,76.8,,11605.95,0.518595,35041.66656,percent of total billed charges,
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,AETNA [1000108],AETNA [100010801],,,76.8,,12204.78,0.518595,35041.66656,percent of total billed charges,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,AETNA [1000108],AETNA [100010801],,,76.8,,283.22,0.518595,35041.66656,percent of total billed charges,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,0.518595,35041.66656,percent of total billed charges,
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,AETNA [1000108],AETNA [100010801],,,76.8,,6491.21,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,76.8,,358.5,0.518595,35041.66656,percent of total billed charges,
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA [1000108],AETNA [100010801],,,76.8,,8075.69,0.518595,35041.66656,percent of total billed charges,
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA [1000108],AETNA [100010801],,,76.8,,8075.69,0.518595,35041.66656,percent of total billed charges,
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA [1000108],AETNA [100010801],,,76.8,,8075.69,0.518595,35041.66656,percent of total billed charges,
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,AETNA [1000108],AETNA [100010801],,,76.8,,8084.24,0.518595,35041.66656,percent of total billed charges,
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,AETNA [1000108],AETNA [100010801],,,76.8,,12204.78,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA [1000108],AETNA [100010801],,,76.8,,10898.76,0.518595,35041.66656,percent of total billed charges,
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,AETNA [1000108],AETNA [100010801],,,76.8,,1485.83,0.518595,35041.66656,percent of total billed charges,
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,AETNA [1000108],AETNA [100010801],,,76.8,,1123.54,0.518595,35041.66656,percent of total billed charges,
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,76.8,,291.29,0.518595,35041.66656,percent of total billed charges,
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,AETNA [1000108],AETNA [100010801],,,76.8,,6579.08,0.518595,35041.66656,percent of total billed charges,
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,AETNA [1000108],AETNA [100010801],,,76.8,,14685.66,0.518595,35041.66656,percent of total billed charges,
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,AETNA [1000108],AETNA [100010801],,,76.8,,854.17,0.518595,35041.66656,percent of total billed charges,
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,AETNA [1000108],AETNA [100010801],,,76.8,,2381.49,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,AETNA [1000108],AETNA [100010801],,,76.8,,872.95,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,AETNA [1000108],AETNA [100010801],,,76.8,,848.35,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA [1000108],AETNA [100010801],,,76.8,,902.09,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,AETNA [1000108],AETNA [100010801],,,76.8,,952.57,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,AETNA [1000108],AETNA [100010801],,,76.8,,980.24,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,AETNA [1000108],AETNA [100010801],,,76.8,,848.35,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA [1000108],AETNA [100010801],,,76.8,,902.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,AETNA [1000108],AETNA [100010801],,,76.8,,4214.39,0.518595,35041.66656,percent of total billed charges,
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,AETNA [1000108],AETNA [100010801],,,76.8,,3904.75,0.518595,35041.66656,percent of total billed charges,
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,AETNA [1000108],AETNA [100010801],,,76.8,,7988,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,AETNA [1000108],AETNA [100010801],,,76.8,,8507.7,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA [1000108],AETNA [100010801],,,76.8,,6668.71,0.518595,35041.66656,percent of total billed charges,
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,AETNA [1000108],AETNA [100010801],,,76.8,,714.54,0.518595,35041.66656,percent of total billed charges,
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,AETNA [1000108],AETNA [100010801],,,76.8,,78.84,0.518595,35041.66656,percent of total billed charges,
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,AETNA [1000108],AETNA [100010801],,,76.8,,78.84,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,AETNA [1000108],AETNA [100010801],,,76.8,,680.21,0.518595,35041.66656,percent of total billed charges,
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,AETNA [1000108],AETNA [100010801],,,76.8,,891.78,0.518595,35041.66656,percent of total billed charges,
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,AETNA [1000108],AETNA [100010801],,,76.8,,5778.9,0.518595,35041.66656,percent of total billed charges,
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,AETNA [1000108],AETNA [100010801],,,76.8,,5615.93,0.518595,35041.66656,percent of total billed charges,
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,AETNA [1000108],AETNA [100010801],,,76.8,,6372.11,0.518595,35041.66656,percent of total billed charges,
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,AETNA [1000108],AETNA [100010801],,,76.8,,5615.93,0.518595,35041.66656,percent of total billed charges,
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,AETNA [1000108],AETNA [100010801],,,76.8,,4341.51,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,AETNA [1000108],AETNA [100010801],,,76.8,,1005.48,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,AETNA [1000108],AETNA [100010801],,,76.8,,880.92,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,AETNA [1000108],AETNA [100010801],,,76.8,,1005.48,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA [1000108],AETNA [100010801],,,76.8,,883.36,0.518595,35041.66656,percent of total billed charges,
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA [1000108],AETNA [100010801],,,76.8,,8839.91,0.518595,35041.66656,percent of total billed charges,
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA [1000108],AETNA [100010801],,,76.8,,8839.91,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,AETNA [1000108],AETNA [100010801],,,76.8,,1117.63,0.518595,35041.66656,percent of total billed charges,
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,AETNA [1000108],AETNA [100010801],,,76.8,,1423.14,0.518595,35041.66656,percent of total billed charges,
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,AETNA [1000108],AETNA [100010801],,,76.8,,1897.38,0.518595,35041.66656,percent of total billed charges,
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,AETNA [1000108],AETNA [100010801],,,76.8,,1897.38,0.518595,35041.66656,percent of total billed charges,
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,AETNA [1000108],AETNA [100010801],,,76.8,,3004.82,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA [1000108],AETNA [100010801],,,76.8,,830.93,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA [1000108],AETNA [100010801],,,76.8,,500.11,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA [1000108],AETNA [100010801],,,76.8,,500.11,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA [1000108],AETNA [100010801],,,76.8,,500.11,0.518595,35041.66656,percent of total billed charges,
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,AETNA [1000108],AETNA [100010801],,,76.8,,8982.49,0.518595,35041.66656,percent of total billed charges,
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,AETNA [1000108],AETNA [100010801],,,76.8,,5558.89,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,AETNA [1000108],AETNA [100010801],,,76.8,,1254.74,0.518595,35041.66656,percent of total billed charges,
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,0.518595,35041.66656,percent of total billed charges,
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,AETNA [1000108],AETNA [100010801],,,76.8,,3155.26,0.518595,35041.66656,percent of total billed charges,
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,AETNA [1000108],AETNA [100010801],,,76.8,,3134.8,0.518595,35041.66656,percent of total billed charges,
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,0.518595,35041.66656,percent of total billed charges,
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,AETNA [1000108],AETNA [100010801],,,76.8,,2639.83,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,AETNA [1000108],AETNA [100010801],,,76.8,,5123.77,0.518595,35041.66656,percent of total billed charges,
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,AETNA [1000108],AETNA [100010801],,,76.8,,6160.25,0.518595,35041.66656,percent of total billed charges,
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,AETNA [1000108],AETNA [100010801],,,76.8,,5045.54,0.518595,35041.66656,percent of total billed charges,
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,AETNA [1000108],AETNA [100010801],,,76.8,,5045.54,0.518595,35041.66656,percent of total billed charges,
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,AETNA [1000108],AETNA [100010801],,,76.8,,5241.1,0.518595,35041.66656,percent of total billed charges,
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,AETNA [1000108],AETNA [100010801],,,76.8,,2493.17,0.518595,35041.66656,percent of total billed charges,
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,AETNA [1000108],AETNA [100010801],,,76.8,,1119.14,0.518595,35041.66656,percent of total billed charges,
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,AETNA [1000108],AETNA [100010801],,,76.8,,4141.87,0.518595,35041.66656,percent of total billed charges,
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,0.518595,35041.66656,percent of total billed charges,
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,0.518595,35041.66656,percent of total billed charges,
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,AETNA [1000108],AETNA [100010801],,,76.8,,6656.99,0.518595,35041.66656,percent of total billed charges,
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,AETNA [1000108],AETNA [100010801],,,76.8,,8181.2,0.518595,35041.66656,percent of total billed charges,
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA [1000108],AETNA [100010801],,,76.8,,24238.46,0.518595,35041.66656,percent of total billed charges,
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA [1000108],AETNA [100010801],,,76.8,,24238.46,0.518595,35041.66656,percent of total billed charges,
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA [1000108],AETNA [100010801],,,76.8,,24238.46,0.518595,35041.66656,percent of total billed charges,
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA [1000108],AETNA [100010801],,,76.8,,24238.46,0.518595,35041.66656,percent of total billed charges,
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,AETNA [1000108],AETNA [100010801],,,76.8,,108.09,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,AETNA [1000108],AETNA [100010801],,,76.8,,236.43,0.518595,35041.66656,percent of total billed charges,
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,AETNA [1000108],AETNA [100010801],,,76.8,,11429.15,0.518595,35041.66656,percent of total billed charges,
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,AETNA [1000108],AETNA [100010801],,,76.8,,12951.9,0.518595,35041.66656,percent of total billed charges,
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,AETNA [1000108],AETNA [100010801],,,76.8,,12951.9,0.518595,35041.66656,percent of total billed charges,
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,AETNA [1000108],AETNA [100010801],,,76.8,,5580.08,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA [1000108],AETNA [100010801],,,76.8,,2695.78,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA [1000108],AETNA [100010801],,,76.8,,2695.78,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA [1000108],AETNA [100010801],,,76.8,,2695.78,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA [1000108],AETNA [100010801],,,76.8,,2695.78,0.518595,35041.66656,percent of total billed charges,
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,AETNA [1000108],AETNA [100010801],,,76.8,,599.86,0.518595,35041.66656,percent of total billed charges,
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,AETNA [1000108],AETNA [100010801],,,76.8,,495.54,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,AETNA [1000108],AETNA [100010801],,,76.8,,412.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,0.518595,35041.66656,percent of total billed charges,
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,AETNA [1000108],AETNA [100010801],,,76.8,,2555.5,0.518595,35041.66656,percent of total billed charges,
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,0.518595,35041.66656,percent of total billed charges,
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,AETNA [1000108],AETNA [100010801],,,76.8,,1797.86,0.518595,35041.66656,percent of total billed charges,
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,AETNA [1000108],AETNA [100010801],,,76.8,,3629.01,0.518595,35041.66656,percent of total billed charges,
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,AETNA [1000108],AETNA [100010801],,,76.8,,6048.35,0.518595,35041.66656,percent of total billed charges,
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,AETNA [1000108],AETNA [100010801],,,76.8,,3523.34,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,AETNA [1000108],AETNA [100010801],,,76.8,,234.73,0.518595,35041.66656,percent of total billed charges,
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,AETNA [1000108],AETNA [100010801],,,76.8,,2055.62,0.518595,35041.66656,percent of total billed charges,
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,AETNA [1000108],AETNA [100010801],,,76.8,,2055.62,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,AETNA [1000108],AETNA [100010801],,,76.8,,890.3,0.518595,35041.66656,percent of total billed charges,
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,0.518595,35041.66656,percent of total billed charges,
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,AETNA [1000108],AETNA [100010801],,,76.8,,3655.43,0.518595,35041.66656,percent of total billed charges,
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,AETNA [1000108],AETNA [100010801],,,76.8,,3655.43,0.518595,35041.66656,percent of total billed charges,
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,AETNA [1000108],AETNA [100010801],,,76.8,,2621.5,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,AETNA [1000108],AETNA [100010801],,,76.8,,1946.87,0.518595,35041.66656,percent of total billed charges,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,AETNA [1000108],AETNA [100010801],,,76.8,,2133.86,0.518595,35041.66656,percent of total billed charges,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,AETNA [1000108],AETNA [100010801],,,76.8,,2133.86,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,AETNA [1000108],AETNA [100010801],,,76.8,,2793.82,0.518595,35041.66656,percent of total billed charges,
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,AETNA [1000108],AETNA [100010801],,,76.8,,3090.8,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA [1000108],AETNA [100010801],,,76.8,,3441.91,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,76.8,,188.21,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,AETNA [1000108],AETNA [100010801],,,76.8,,1807.43,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,AETNA [1000108],AETNA [100010801],,,76.8,,1612.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA [1000108],AETNA [100010801],,,76.8,,1880.7,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA [1000108],AETNA [100010801],,,76.8,,1880.7,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA [1000108],AETNA [100010801],,,76.8,,1880.7,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,AETNA [1000108],AETNA [100010801],,,76.8,,3500.59,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,AETNA [1000108],AETNA [100010801],,,76.8,,3329.12,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,AETNA [1000108],AETNA [100010801],,,76.8,,3329.12,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,AETNA [1000108],AETNA [100010801],,,76.8,,948.5,0.518595,35041.66656,percent of total billed charges,
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,AETNA [1000108],AETNA [100010801],,,76.8,,4172.02,0.518595,35041.66656,percent of total billed charges,
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,AETNA [1000108],AETNA [100010801],,,76.8,,4172.02,0.518595,35041.66656,percent of total billed charges,
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,AETNA [1000108],AETNA [100010801],,,76.8,,163.79,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,76.8,,134.44,0.518595,35041.66656,percent of total billed charges,
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,AETNA [1000108],AETNA [100010801],,,76.8,,387.59,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,AETNA [1000108],AETNA [100010801],,,76.8,,428.01,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,AETNA [1000108],AETNA [100010801],,,76.8,,751.02,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA [1000108],AETNA [100010801],,,76.8,,9604.13,0.518595,35041.66656,percent of total billed charges,
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA [1000108],AETNA [100010801],,,76.8,,9604.13,0.518595,35041.66656,percent of total billed charges,
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA [1000108],AETNA [100010801],,,76.8,,9604.13,0.518595,35041.66656,percent of total billed charges,
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA [1000108],AETNA [100010801],,,76.8,,10978.6,0.518595,35041.66656,percent of total billed charges,
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA [1000108],AETNA [100010801],,,76.8,,10978.6,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,76.8,,1432.92,0.518595,35041.66656,percent of total billed charges,
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,0.518595,35041.66656,percent of total billed charges,
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,AETNA [1000108],AETNA [100010801],,,76.8,,2.06,0.518595,35041.66656,percent of total billed charges,
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,AETNA [1000108],AETNA [100010801],,,76.8,,15398.55,0.518595,35041.66656,percent of total billed charges,
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,AETNA [1000108],AETNA [100010801],,,76.8,,16.44,0.518595,35041.66656,percent of total billed charges,
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,AETNA [1000108],AETNA [100010801],,,76.8,,16.44,0.518595,35041.66656,percent of total billed charges,
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,AETNA [1000108],AETNA [100010801],,,76.8,,22.41,0.518595,35041.66656,percent of total billed charges,
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,0.518595,35041.66656,percent of total billed charges,
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,0.518595,35041.66656,percent of total billed charges,
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,AETNA [1000108],AETNA [100010801],,,76.8,,13818.06,0.518595,35041.66656,percent of total billed charges,
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,AETNA [1000108],AETNA [100010801],,,76.8,,15551.12,0.518595,35041.66656,percent of total billed charges,
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,AETNA [1000108],AETNA [100010801],,,76.8,,15551.12,0.518595,35041.66656,percent of total billed charges,
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,AETNA [1000108],AETNA [100010801],,,76.8,,18655.77,0.518595,35041.66656,percent of total billed charges,
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,AETNA [1000108],AETNA [100010801],,,76.8,,13818.06,0.518595,35041.66656,percent of total billed charges,
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,AETNA [1000108],AETNA [100010801],,,76.8,,16811.51,0.518595,35041.66656,percent of total billed charges,
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,AETNA [1000108],AETNA [100010801],,,76.8,,417.21,0.518595,35041.66656,percent of total billed charges,
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA [1000108],AETNA [100010801],,,76.8,,13280.54,0.518595,35041.66656,percent of total billed charges,
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA [1000108],AETNA [100010801],,,76.8,,13280.54,0.518595,35041.66656,percent of total billed charges,
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,AETNA [1000108],AETNA [100010801],,,76.8,,14494.6,0.518595,35041.66656,percent of total billed charges,
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA [1000108],AETNA [100010801],,,76.8,,13280.54,0.518595,35041.66656,percent of total billed charges,
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,AETNA [1000108],AETNA [100010801],,,76.8,,14828.24,0.518595,35041.66656,percent of total billed charges,
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,AETNA [1000108],AETNA [100010801],,,76.8,,12659.6,0.518595,35041.66656,percent of total billed charges,
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,AETNA [1000108],AETNA [100010801],,,76.8,,15171.14,0.518595,35041.66656,percent of total billed charges,
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,AETNA [1000108],AETNA [100010801],,,76.8,,7945.23,0.518595,35041.66656,percent of total billed charges,
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,AETNA [1000108],AETNA [100010801],,,76.8,,370.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,AETNA [1000108],AETNA [100010801],,,76.8,,4669.08,0.518595,35041.66656,percent of total billed charges,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA [1000108],AETNA [100010801],,,76.8,,542.24,0.518595,35041.66656,percent of total billed charges,
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,AETNA [1000108],AETNA [100010801],,,76.8,,353.17,0.518595,35041.66656,percent of total billed charges,
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,AETNA [1000108],AETNA [100010801],,,76.8,,609.68,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,AETNA [1000108],AETNA [100010801],,,76.8,,5690.9,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,AETNA [1000108],AETNA [100010801],,,76.8,,7802.99,0.518595,35041.66656,percent of total billed charges,
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,0.518595,35041.66656,percent of total billed charges,
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,0.518595,35041.66656,percent of total billed charges,
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,AETNA [1000108],AETNA [100010801],,,76.8,,892.11,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA [1000108],AETNA [100010801],,,76.8,,5593.11,0.518595,35041.66656,percent of total billed charges,
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,AETNA [1000108],AETNA [100010801],,,76.8,,581.89,0.518595,35041.66656,percent of total billed charges,
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,AETNA [1000108],AETNA [100010801],,,76.8,,581.89,0.518595,35041.66656,percent of total billed charges,
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,AETNA [1000108],AETNA [100010801],,,76.8,,592.87,0.518595,35041.66656,percent of total billed charges,
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA [1000108],AETNA [100010801],,,76.8,,3895.79,0.518595,35041.66656,percent of total billed charges,
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA [1000108],AETNA [100010801],,,76.8,,3895.79,0.518595,35041.66656,percent of total billed charges,
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA [1000108],AETNA [100010801],,,76.8,,3895.79,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,AETNA [1000108],AETNA [100010801],,,76.8,,21833.26,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,AETNA [1000108],AETNA [100010801],,,76.8,,552.09,0.518595,35041.66656,percent of total billed charges,
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,AETNA [1000108],AETNA [100010801],,,76.8,,556.8,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,AETNA [1000108],AETNA [100010801],,,76.8,,5221.55,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,AETNA [1000108],AETNA [100010801],,,76.8,,4984.26,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,AETNA [1000108],AETNA [100010801],,,76.8,,4984.26,0.518595,35041.66656,percent of total billed charges,
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,AETNA [1000108],AETNA [100010801],,,76.8,,2287.86,0.518595,35041.66656,percent of total billed charges,
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA [1000108],AETNA [100010801],,,76.8,,10550.86,0.518595,35041.66656,percent of total billed charges,
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA [1000108],AETNA [100010801],,,76.8,,10550.86,0.518595,35041.66656,percent of total billed charges,
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA [1000108],AETNA [100010801],,,76.8,,10550.86,0.518595,35041.66656,percent of total billed charges,
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA [1000108],AETNA [100010801],,,76.8,,10550.86,0.518595,35041.66656,percent of total billed charges,
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,AETNA [1000108],AETNA [100010801],,,76.8,,11388.51,0.518595,35041.66656,percent of total billed charges,
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,0.518595,35041.66656,percent of total billed charges,
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,0.518595,35041.66656,percent of total billed charges,
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,AETNA [1000108],AETNA [100010801],,,76.8,,708.04,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,AETNA [1000108],AETNA [100010801],,,76.8,,4497.96,0.518595,35041.66656,percent of total billed charges,
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,AETNA [1000108],AETNA [100010801],,,76.8,,15669.46,0.518595,35041.66656,percent of total billed charges,
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,AETNA [1000108],AETNA [100010801],,,76.8,,17237.83,0.518595,35041.66656,percent of total billed charges,
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA [1000108],AETNA [100010801],,,76.8,,630.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA [1000108],AETNA [100010801],,,76.8,,624.25,0.518595,35041.66656,percent of total billed charges,
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA [1000108],AETNA [100010801],,,76.8,,624.25,0.518595,35041.66656,percent of total billed charges,
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA [1000108],AETNA [100010801],,,76.8,,624.25,0.518595,35041.66656,percent of total billed charges,
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA [1000108],AETNA [100010801],,,76.8,,630.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA [1000108],AETNA [100010801],,,76.8,,630.51,0.518595,35041.66656,percent of total billed charges,
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA [1000108],AETNA [100010801],,,76.8,,585.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA [1000108],AETNA [100010801],,,76.8,,585.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA [1000108],AETNA [100010801],,,76.8,,585.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA [1000108],AETNA [100010801],,,76.8,,585.03,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,AETNA [1000108],AETNA [100010801],,,76.8,,993.27,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,0.518595,35041.66656,percent of total billed charges,
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,76.8,,71.7,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,AETNA [1000108],AETNA [100010801],,,76.8,,315.93,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,AETNA [1000108],AETNA [100010801],,,76.8,,637.64,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,AETNA [1000108],AETNA [100010801],,,76.8,,252.07,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,AETNA [1000108],AETNA [100010801],,,76.8,,252.07,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,AETNA [1000108],AETNA [100010801],,,76.8,,681.15,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,AETNA [1000108],AETNA [100010801],,,76.8,,566.79,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,AETNA [1000108],AETNA [100010801],,,76.8,,566.79,0.518595,35041.66656,percent of total billed charges,
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,76.8,,1175.44,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,0.518595,35041.66656,percent of total billed charges,
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,AETNA [1000108],AETNA [100010801],,,76.8,,147.89,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA [1000108],AETNA [100010801],,,76.8,,282.32,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA [1000108],AETNA [100010801],,,76.8,,282.32,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA [1000108],AETNA [100010801],,,76.8,,282.32,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,AETNA [1000108],AETNA [100010801],,,76.8,,77.66,0.518595,35041.66656,percent of total billed charges,
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,AETNA [1000108],AETNA [100010801],,,76.8,,121,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,AETNA [1000108],AETNA [100010801],,,76.8,,1359.64,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,AETNA [1000108],AETNA [100010801],,,76.8,,1313.68,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,AETNA [1000108],AETNA [100010801],,,76.8,,1585.97,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,AETNA [1000108],AETNA [100010801],,,76.8,,1212.81,0.518595,35041.66656,percent of total billed charges,
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,AETNA [1000108],AETNA [100010801],,,76.8,,2634.44,0.518595,35041.66656,percent of total billed charges,
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,AETNA [1000108],AETNA [100010801],,,76.8,,1997.54,0.518595,35041.66656,percent of total billed charges,
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,AETNA [1000108],AETNA [100010801],,,76.8,,1997.54,0.518595,35041.66656,percent of total billed charges,
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,AETNA [1000108],AETNA [100010801],,,76.8,,3084.2,0.518595,35041.66656,percent of total billed charges,
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,AETNA [1000108],AETNA [100010801],,,76.8,,5140.88,0.518595,35041.66656,percent of total billed charges,
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,AETNA [1000108],AETNA [100010801],,,76.8,,8395.63,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,AETNA [1000108],AETNA [100010801],,,76.8,,1211.79,0.518595,35041.66656,percent of total billed charges,
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,AETNA [1000108],AETNA [100010801],,,76.8,,1099.12,0.518595,35041.66656,percent of total billed charges,
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,AETNA [1000108],AETNA [100010801],,,76.8,,1099.12,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,AETNA [1000108],AETNA [100010801],,,76.8,,625.14,0.518595,35041.66656,percent of total billed charges,
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA [1000108],AETNA [100010801],,,76.8,,1166.28,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA [1000108],AETNA [100010801],,,76.8,,1166.28,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA [1000108],AETNA [100010801],,,76.8,,1166.28,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA [1000108],AETNA [100010801],,,76.8,,1199.86,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA [1000108],AETNA [100010801],,,76.8,,1199.86,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA [1000108],AETNA [100010801],,,76.8,,1199.86,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,AETNA [1000108],AETNA [100010801],,,76.8,,243.78,0.518595,35041.66656,percent of total billed charges,
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,AETNA [1000108],AETNA [100010801],,,76.8,,666.82,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,AETNA [1000108],AETNA [100010801],,,76.8,,347.75,0.518595,35041.66656,percent of total billed charges,
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,AETNA [1000108],AETNA [100010801],,,76.8,,827.18,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,AETNA [1000108],AETNA [100010801],,,76.8,,5027.29,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,AETNA [1000108],AETNA [100010801],,,76.8,,168.05,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,AETNA [1000108],AETNA [100010801],,,76.8,,171.41,0.518595,35041.66656,percent of total billed charges,
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,AETNA [1000108],AETNA [100010801],,,76.8,,15106.27,0.518595,35041.66656,percent of total billed charges,
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,AETNA [1000108],AETNA [100010801],,,76.8,,15106.27,0.518595,35041.66656,percent of total billed charges,
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,AETNA [1000108],AETNA [100010801],,,76.8,,1261.95,0.518595,35041.66656,percent of total billed charges,
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,AETNA [1000108],AETNA [100010801],,,76.8,,230.43,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,AETNA [1000108],AETNA [100010801],,,76.8,,1853.22,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,AETNA [1000108],AETNA [100010801],,,76.8,,1923.45,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,AETNA [1000108],AETNA [100010801],,,76.8,,2021.15,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,AETNA [1000108],AETNA [100010801],,,76.8,,1894.63,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,AETNA [1000108],AETNA [100010801],,,76.8,,1952.38,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,AETNA [1000108],AETNA [100010801],,,76.8,,864.89,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,AETNA [1000108],AETNA [100010801],,,76.8,,1783,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,AETNA [1000108],AETNA [100010801],,,76.8,,875.22,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,0.518595,35041.66656,percent of total billed charges,
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,AETNA [1000108],AETNA [100010801],,,76.8,,1689.38,0.518595,35041.66656,percent of total billed charges,
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA [1000108],AETNA [100010801],,,76.8,,917.96,0.518595,35041.66656,percent of total billed charges,
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,AETNA [1000108],AETNA [100010801],,,76.8,,1023.81,0.518595,35041.66656,percent of total billed charges,
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA [1000108],AETNA [100010801],,,76.8,,917.96,0.518595,35041.66656,percent of total billed charges,
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,AETNA [1000108],AETNA [100010801],,,76.8,,7476.86,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,AETNA [1000108],AETNA [100010801],,,76.8,,7753.46,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,AETNA [1000108],AETNA [100010801],,,76.8,,9812.53,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,AETNA [1000108],AETNA [100010801],,,76.8,,7753.46,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,AETNA [1000108],AETNA [100010801],,,76.8,,8111.33,0.518595,35041.66656,percent of total billed charges,
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,AETNA [1000108],AETNA [100010801],,,76.8,,8109.9,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,AETNA [1000108],AETNA [100010801],,,76.8,,8111.33,0.518595,35041.66656,percent of total billed charges,
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,AETNA [1000108],AETNA [100010801],,,76.8,,8109.9,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,AETNA [1000108],AETNA [100010801],,,76.8,,1680.3,0.518595,35041.66656,percent of total billed charges,
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,AETNA [1000108],AETNA [100010801],,,76.8,,1023.81,0.518595,35041.66656,percent of total billed charges,
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,0.518595,35041.66656,percent of total billed charges,
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,0.518595,35041.66656,percent of total billed charges,
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,AETNA [1000108],AETNA [100010801],,,76.8,,1663.73,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,AETNA [1000108],AETNA [100010801],,,76.8,,1680.3,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,AETNA [1000108],AETNA [100010801],,,76.8,,8266.86,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA [1000108],AETNA [100010801],,,76.8,,6769.76,0.518595,35041.66656,percent of total billed charges,
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA [1000108],AETNA [100010801],,,76.8,,6769.76,0.518595,35041.66656,percent of total billed charges,
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA [1000108],AETNA [100010801],,,76.8,,6769.76,0.518595,35041.66656,percent of total billed charges,
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,AETNA [1000108],AETNA [100010801],,,76.8,,8266.83,0.518595,35041.66656,percent of total billed charges,
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA [1000108],AETNA [100010801],,,76.8,,6769.76,0.518595,35041.66656,percent of total billed charges,
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,AETNA [1000108],AETNA [100010801],,,76.8,,680.21,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,AETNA [1000108],AETNA [100010801],,,76.8,,1410.52,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,AETNA [1000108],AETNA [100010801],,,76.8,,1192.74,0.518595,35041.66656,percent of total billed charges,
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,AETNA [1000108],AETNA [100010801],,,76.8,,2663.04,0.518595,35041.66656,percent of total billed charges,
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,AETNA [1000108],AETNA [100010801],,,76.8,,2395.1,0.518595,35041.66656,percent of total billed charges,
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,AETNA [1000108],AETNA [100010801],,,76.8,,1842.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,AETNA [1000108],AETNA [100010801],,,76.8,,1708.71,0.518595,35041.66656,percent of total billed charges,
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,AETNA [1000108],AETNA [100010801],,,76.8,,1655.79,0.518595,35041.66656,percent of total billed charges,
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,AETNA [1000108],AETNA [100010801],,,76.8,,1981.46,0.518595,35041.66656,percent of total billed charges,
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,AETNA [1000108],AETNA [100010801],,,76.8,,2007.38,0.518595,35041.66656,percent of total billed charges,
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,AETNA [1000108],AETNA [100010801],,,76.8,,1464.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,AETNA [1000108],AETNA [100010801],,,76.8,,600.13,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,AETNA [1000108],AETNA [100010801],,,76.8,,725.16,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,AETNA [1000108],AETNA [100010801],,,76.8,,903.71,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,AETNA [1000108],AETNA [100010801],,,76.8,,995.67,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,AETNA [1000108],AETNA [100010801],,,76.8,,985.13,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,AETNA [1000108],AETNA [100010801],,,76.8,,1224.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,AETNA [1000108],AETNA [100010801],,,76.8,,973.93,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,AETNA [1000108],AETNA [100010801],,,76.8,,1010.57,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,AETNA [1000108],AETNA [100010801],,,76.8,,1340.31,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,AETNA [1000108],AETNA [100010801],,,76.8,,3491.62,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,AETNA [1000108],AETNA [100010801],,,76.8,,1904.27,0.518595,35041.66656,percent of total billed charges,
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,AETNA [1000108],AETNA [100010801],,,76.8,,5560.52,0.518595,35041.66656,percent of total billed charges,
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,AETNA [1000108],AETNA [100010801],,,76.8,,2609.58,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,AETNA [1000108],AETNA [100010801],,,76.8,,2722.33,0.518595,35041.66656,percent of total billed charges,
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,AETNA [1000108],AETNA [100010801],,,76.8,,2870.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA [1000108],AETNA [100010801],,,76.8,,1241.59,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,AETNA [1000108],AETNA [100010801],,,76.8,,3644.44,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,AETNA [1000108],AETNA [100010801],,,76.8,,1976.21,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,AETNA [1000108],AETNA [100010801],,,76.8,,1917.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,AETNA [1000108],AETNA [100010801],,,76.8,,2966.15,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,AETNA [1000108],AETNA [100010801],,,76.8,,2494.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,AETNA [1000108],AETNA [100010801],,,76.8,,1954.21,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,0.518595,35041.66656,percent of total billed charges,
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,0.518595,35041.66656,percent of total billed charges,
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,AETNA [1000108],AETNA [100010801],,,76.8,,1754.51,0.518595,35041.66656,percent of total billed charges,
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,AETNA [1000108],AETNA [100010801],,,76.8,,1749.05,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA [1000108],AETNA [100010801],,,76.8,,16907.04,0.518595,35041.66656,percent of total billed charges,
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,0.518595,35041.66656,percent of total billed charges,
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,AETNA [1000108],AETNA [100010801],,,76.8,,15548.89,0.518595,35041.66656,percent of total billed charges,
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,AETNA [1000108],AETNA [100010801],,,76.8,,631.86,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA [1000108],AETNA [100010801],,,76.8,,542.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA [1000108],AETNA [100010801],,,76.8,,542.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,AETNA [1000108],AETNA [100010801],,,76.8,,659.02,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,AETNA [1000108],AETNA [100010801],,,76.8,,659.02,0.518595,35041.66656,percent of total billed charges,
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,76.8,,2053.2,0.518595,35041.66656,percent of total billed charges,
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,76.8,,2053.2,0.518595,35041.66656,percent of total billed charges,
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,AETNA [1000108],AETNA [100010801],,,76.8,,2661.83,0.518595,35041.66656,percent of total billed charges,
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,AETNA [1000108],AETNA [100010801],,,76.8,,2661.83,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,AETNA [1000108],AETNA [100010801],,,76.8,,2188.93,0.518595,35041.66656,percent of total billed charges,
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA [1000108],AETNA [100010801],,,76.8,,1343.36,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,0.518595,35041.66656,percent of total billed charges,
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,AETNA [1000108],AETNA [100010801],,,76.8,,6600.27,0.518595,35041.66656,percent of total billed charges,
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA [1000108],AETNA [100010801],,,76.8,,3531.75,0.518595,35041.66656,percent of total billed charges,
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,AETNA [1000108],AETNA [100010801],,,76.8,,4157.61,0.518595,35041.66656,percent of total billed charges,
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA [1000108],AETNA [100010801],,,76.8,,3531.75,0.518595,35041.66656,percent of total billed charges,
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA [1000108],AETNA [100010801],,,76.8,,3531.75,0.518595,35041.66656,percent of total billed charges,
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,76.8,,380.91,0.518595,35041.66656,percent of total billed charges,
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,0.518595,35041.66656,percent of total billed charges,
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,76.8,,1119.47,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA [1000108],AETNA [100010801],,,76.8,,5738.49,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA [1000108],AETNA [100010801],,,76.8,,777.37,0.518595,35041.66656,percent of total billed charges,
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA [1000108],AETNA [100010801],,,76.8,,777.37,0.518595,35041.66656,percent of total billed charges,
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA [1000108],AETNA [100010801],,,76.8,,777.37,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA [1000108],AETNA [100010801],,,76.8,,830.93,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,AETNA [1000108],AETNA [100010801],,,76.8,,918.86,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,AETNA [1000108],AETNA [100010801],,,76.8,,1008.74,0.518595,35041.66656,percent of total billed charges,
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA [1000108],AETNA [100010801],,,76.8,,5738.49,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA [1000108],AETNA [100010801],,,76.8,,2750.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,AETNA [1000108],AETNA [100010801],,,76.8,,2224.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,AETNA [1000108],AETNA [100010801],,,76.8,,2224.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA [1000108],AETNA [100010801],,,76.8,,2750.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA [1000108],AETNA [100010801],,,76.8,,2750.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA [1000108],AETNA [100010801],,,76.8,,2750.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA [1000108],AETNA [100010801],,,76.8,,2742.49,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,AETNA [1000108],AETNA [100010801],,,76.8,,3750.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,AETNA [1000108],AETNA [100010801],,,76.8,,926.1,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,AETNA [1000108],AETNA [100010801],,,76.8,,926.1,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA [1000108],AETNA [100010801],,,76.8,,8868.43,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA [1000108],AETNA [100010801],,,76.8,,118.26,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA [1000108],AETNA [100010801],,,76.8,,118.26,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA [1000108],AETNA [100010801],,,76.8,,118.26,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA [1000108],AETNA [100010801],,,76.8,,118.26,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA [1000108],AETNA [100010801],,,76.8,,114.59,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA [1000108],AETNA [100010801],,,76.8,,114.59,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA [1000108],AETNA [100010801],,,76.8,,114.59,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA [1000108],AETNA [100010801],,,76.8,,114.59,0.518595,35041.66656,percent of total billed charges,
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,AETNA [1000108],AETNA [100010801],,,76.8,,98.23,0.518595,35041.66656,percent of total billed charges,
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA [1000108],AETNA [100010801],,,76.8,,1994.69,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,AETNA [1000108],AETNA [100010801],,,76.8,,1902.88,0.518595,35041.66656,percent of total billed charges,
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,AETNA [1000108],AETNA [100010801],,,76.8,,6434.04,0.518595,35041.66656,percent of total billed charges,
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,AETNA [1000108],AETNA [100010801],,,76.8,,7858.97,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,AETNA [1000108],AETNA [100010801],,,76.8,,4478.41,0.518595,35041.66656,percent of total billed charges,
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,AETNA [1000108],AETNA [100010801],,,76.8,,5655.05,0.518595,35041.66656,percent of total billed charges,
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,AETNA [1000108],AETNA [100010801],,,76.8,,7419.82,0.518595,35041.66656,percent of total billed charges,
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,AETNA [1000108],AETNA [100010801],,,76.8,,8087.09,0.518595,35041.66656,percent of total billed charges,
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA [1000108],AETNA [100010801],,,76.8,,192.7,0.518595,35041.66656,percent of total billed charges,
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA [1000108],AETNA [100010801],,,76.8,,192.7,0.518595,35041.66656,percent of total billed charges,
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA [1000108],AETNA [100010801],,,76.8,,192.7,0.518595,35041.66656,percent of total billed charges,
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA [1000108],AETNA [100010801],,,76.8,,811.12,0.518595,35041.66656,percent of total billed charges,
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA [1000108],AETNA [100010801],,,76.8,,811.12,0.518595,35041.66656,percent of total billed charges,
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA [1000108],AETNA [100010801],,,76.8,,811.12,0.518595,35041.66656,percent of total billed charges,
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA [1000108],AETNA [100010801],,,76.8,,811.12,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA [1000108],AETNA [100010801],,,76.8,,1343.36,0.518595,35041.66656,percent of total billed charges,
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,0.518595,35041.66656,percent of total billed charges,
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,AETNA [1000108],AETNA [100010801],,,76.8,,10.37,0.518595,35041.66656,percent of total billed charges,
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,AETNA [1000108],AETNA [100010801],,,76.8,,501.63,0.518595,35041.66656,percent of total billed charges,
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA [1000108],AETNA [100010801],,,76.8,,1928.57,0.518595,35041.66656,percent of total billed charges,
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA [1000108],AETNA [100010801],,,76.8,,1928.57,0.518595,35041.66656,percent of total billed charges,
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA [1000108],AETNA [100010801],,,76.8,,1928.57,0.518595,35041.66656,percent of total billed charges,
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA [1000108],AETNA [100010801],,,76.8,,1928.57,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,AETNA [1000108],AETNA [100010801],,,76.8,,231.86,0.518595,35041.66656,percent of total billed charges,
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,AETNA [1000108],AETNA [100010801],,,76.8,,231.86,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,AETNA [1000108],AETNA [100010801],,,76.8,,285.14,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,AETNA [1000108],AETNA [100010801],,,76.8,,63.68,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,AETNA [1000108],AETNA [100010801],,,76.8,,140.54,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,AETNA [1000108],AETNA [100010801],,,76.8,,101.81,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,AETNA [1000108],AETNA [100010801],,,76.8,,111.85,0.518595,35041.66656,percent of total billed charges,
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,AETNA [1000108],AETNA [100010801],,,76.8,,479.81,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA [1000108],AETNA [100010801],,,76.8,,955.08,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA [1000108],AETNA [100010801],,,76.8,,955.08,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA [1000108],AETNA [100010801],,,76.8,,1176.45,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA [1000108],AETNA [100010801],,,76.8,,955.08,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA [1000108],AETNA [100010801],,,76.8,,955.08,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,AETNA [1000108],AETNA [100010801],,,76.8,,2034.05,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,AETNA [1000108],AETNA [100010801],,,76.8,,884.25,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,AETNA [1000108],AETNA [100010801],,,76.8,,1578.73,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,AETNA [1000108],AETNA [100010801],,,76.8,,1824.98,0.518595,35041.66656,percent of total billed charges,
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,AETNA [1000108],AETNA [100010801],,,76.8,,4.39,0.518595,35041.66656,percent of total billed charges,
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,AETNA [1000108],AETNA [100010801],,,76.8,,8.96,0.518595,35041.66656,percent of total billed charges,
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,AETNA [1000108],AETNA [100010801],,,76.8,,3.86,0.518595,35041.66656,percent of total billed charges,
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,AETNA [1000108],AETNA [100010801],,,76.8,,4.17,0.518595,35041.66656,percent of total billed charges,
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,AETNA [1000108],AETNA [100010801],,,76.8,,21.69,0.518595,35041.66656,percent of total billed charges,
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,AETNA [1000108],AETNA [100010801],,,76.8,,3387.55,0.518595,35041.66656,percent of total billed charges,
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,AETNA [1000108],AETNA [100010801],,,76.8,,13111.36,0.518595,35041.66656,percent of total billed charges,
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,AETNA [1000108],AETNA [100010801],,,76.8,,7887.48,0.518595,35041.66656,percent of total billed charges,
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,AETNA [1000108],AETNA [100010801],,,76.8,,4866.27,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,AETNA [1000108],AETNA [100010801],,,76.8,,1291.62,0.518595,35041.66656,percent of total billed charges,
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,AETNA [1000108],AETNA [100010801],,,76.8,,3349.25,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA [1000108],AETNA [100010801],,,76.8,,504.15,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA [1000108],AETNA [100010801],,,76.8,,504.15,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA [1000108],AETNA [100010801],,,76.8,,504.15,0.518595,35041.66656,percent of total billed charges,
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA [1000108],AETNA [100010801],,,76.8,,2239.09,0.518595,35041.66656,percent of total billed charges,
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA [1000108],AETNA [100010801],,,76.8,,2239.09,0.518595,35041.66656,percent of total billed charges,
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA [1000108],AETNA [100010801],,,76.8,,2239.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,AETNA [1000108],AETNA [100010801],,,76.8,,1857.29,0.518595,35041.66656,percent of total billed charges,
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,AETNA [1000108],AETNA [100010801],,,76.8,,2016.05,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,AETNA [1000108],AETNA [100010801],,,76.8,,2041.18,0.518595,35041.66656,percent of total billed charges,
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,AETNA [1000108],AETNA [100010801],,,76.8,,1574.98,0.518595,35041.66656,percent of total billed charges,
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,AETNA [1000108],AETNA [100010801],,,76.8,,2005.06,0.518595,35041.66656,percent of total billed charges,
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,AETNA [1000108],AETNA [100010801],,,76.8,,1882.94,0.518595,35041.66656,percent of total billed charges,
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,AETNA [1000108],AETNA [100010801],,,76.8,,1882.94,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,AETNA [1000108],AETNA [100010801],,,76.8,,1873.34,0.518595,35041.66656,percent of total billed charges,
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,AETNA [1000108],AETNA [100010801],,,76.8,,1956.74,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,AETNA [1000108],AETNA [100010801],,,76.8,,2139.4,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,AETNA [1000108],AETNA [100010801],,,76.8,,1334.4,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,AETNA [1000108],AETNA [100010801],,,76.8,,1467.56,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,AETNA [1000108],AETNA [100010801],,,76.8,,1392.17,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,AETNA [1000108],AETNA [100010801],,,76.8,,1958.33,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,AETNA [1000108],AETNA [100010801],,,76.8,,234.15,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA [1000108],AETNA [100010801],,,76.8,,1961.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA [1000108],AETNA [100010801],,,76.8,,1961.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA [1000108],AETNA [100010801],,,76.8,,1961.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,AETNA [1000108],AETNA [100010801],,,76.8,,1834.61,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA [1000108],AETNA [100010801],,,76.8,,1990.62,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA [1000108],AETNA [100010801],,,76.8,,1990.62,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA [1000108],AETNA [100010801],,,76.8,,1990.62,0.518595,35041.66656,percent of total billed charges,
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,AETNA [1000108],AETNA [100010801],,,76.8,,9053.78,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,AETNA [1000108],AETNA [100010801],,,76.8,,723.06,0.518595,35041.66656,percent of total billed charges,
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,AETNA [1000108],AETNA [100010801],,,76.8,,260.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,AETNA [1000108],AETNA [100010801],,,76.8,,288.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,0.518595,35041.66656,percent of total billed charges,
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,AETNA [1000108],AETNA [100010801],,,76.8,,312.98,0.518595,35041.66656,percent of total billed charges,
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,AETNA [1000108],AETNA [100010801],,,76.8,,4794.56,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,AETNA [1000108],AETNA [100010801],,,76.8,,3833.04,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA [1000108],AETNA [100010801],,,76.8,,7473.78,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,AETNA [1000108],AETNA [100010801],,,76.8,,6473.15,0.518595,35041.66656,percent of total billed charges,
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,AETNA [1000108],AETNA [100010801],,,76.8,,1180.53,0.518595,35041.66656,percent of total billed charges,
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,AETNA [1000108],AETNA [100010801],,,76.8,,1164.24,0.518595,35041.66656,percent of total billed charges,
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,AETNA [1000108],AETNA [100010801],,,76.8,,1164.24,0.518595,35041.66656,percent of total billed charges,
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,0.518595,35041.66656,percent of total billed charges,
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA [1000108],AETNA [100010801],,,76.8,,4050.29,0.518595,35041.66656,percent of total billed charges,
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA [1000108],AETNA [100010801],,,76.8,,4050.29,0.518595,35041.66656,percent of total billed charges,
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA [1000108],AETNA [100010801],,,76.8,,4050.29,0.518595,35041.66656,percent of total billed charges,
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,AETNA [1000108],AETNA [100010801],,,76.8,,3107.56,0.518595,35041.66656,percent of total billed charges,
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,AETNA [1000108],AETNA [100010801],,,76.8,,3591.45,0.518595,35041.66656,percent of total billed charges,
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,AETNA [1000108],AETNA [100010801],,,76.8,,3591.45,0.518595,35041.66656,percent of total billed charges,
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA [1000108],AETNA [100010801],,,76.8,,3511.15,0.518595,35041.66656,percent of total billed charges,
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA [1000108],AETNA [100010801],,,76.8,,3511.15,0.518595,35041.66656,percent of total billed charges,
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA [1000108],AETNA [100010801],,,76.8,,3511.15,0.518595,35041.66656,percent of total billed charges,
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,AETNA [1000108],AETNA [100010801],,,76.8,,3874.28,0.518595,35041.66656,percent of total billed charges,
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,AETNA [1000108],AETNA [100010801],,,76.8,,4692.74,0.518595,35041.66656,percent of total billed charges,
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,AETNA [1000108],AETNA [100010801],,,76.8,,7699.79,0.518595,35041.66656,percent of total billed charges,
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,AETNA [1000108],AETNA [100010801],,,76.8,,6157.19,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,AETNA [1000108],AETNA [100010801],,,76.8,,428.41,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,AETNA [1000108],AETNA [100010801],,,76.8,,550.3,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,AETNA [1000108],AETNA [100010801],,,76.8,,550.3,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA [1000108],AETNA [100010801],,,76.8,,611.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA [1000108],AETNA [100010801],,,76.8,,611.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA [1000108],AETNA [100010801],,,76.8,,611.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,AETNA [1000108],AETNA [100010801],,,76.8,,855.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,AETNA [1000108],AETNA [100010801],,,76.8,,1410.12,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,AETNA [1000108],AETNA [100010801],,,76.8,,1410.12,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,AETNA [1000108],AETNA [100010801],,,76.8,,1590.87,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,AETNA [1000108],AETNA [100010801],,,76.8,,1765.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,AETNA [1000108],AETNA [100010801],,,76.8,,514.45,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,AETNA [1000108],AETNA [100010801],,,76.8,,557.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,AETNA [1000108],AETNA [100010801],,,76.8,,690.12,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,AETNA [1000108],AETNA [100010801],,,76.8,,826.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,AETNA [1000108],AETNA [100010801],,,76.8,,826.34,0.518595,35041.66656,percent of total billed charges,
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,AETNA [1000108],AETNA [100010801],,,76.8,,890.69,0.518595,35041.66656,percent of total billed charges,
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,AETNA [1000108],AETNA [100010801],,,76.8,,8453.98,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,AETNA [1000108],AETNA [100010801],,,76.8,,1105.67,0.518595,35041.66656,percent of total billed charges,
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,AETNA [1000108],AETNA [100010801],,,76.8,,180.1,0.518595,35041.66656,percent of total billed charges,
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,AETNA [1000108],AETNA [100010801],,,76.8,,180.1,0.518595,35041.66656,percent of total billed charges,
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,AETNA [1000108],AETNA [100010801],,,76.8,,221.96,0.518595,35041.66656,percent of total billed charges,
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,AETNA [1000108],AETNA [100010801],,,76.8,,221.96,0.518595,35041.66656,percent of total billed charges,
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,AETNA [1000108],AETNA [100010801],,,76.8,,243.78,0.518595,35041.66656,percent of total billed charges,
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,76.8,,272.91,0.518595,35041.66656,percent of total billed charges,
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,76.8,,272.91,0.518595,35041.66656,percent of total billed charges,
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,AETNA [1000108],AETNA [100010801],,,76.8,,487.56,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,AETNA [1000108],AETNA [100010801],,,76.8,,669.5,0.518595,35041.66656,percent of total billed charges,
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA [1000108],AETNA [100010801],,,76.8,,3993.57,0.518595,35041.66656,percent of total billed charges,
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA [1000108],AETNA [100010801],,,76.8,,3993.57,0.518595,35041.66656,percent of total billed charges,
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,AETNA [1000108],AETNA [100010801],,,76.8,,9174.97,0.518595,35041.66656,percent of total billed charges,
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,AETNA [1000108],AETNA [100010801],,,76.8,,6461.74,0.518595,35041.66656,percent of total billed charges,
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,AETNA [1000108],AETNA [100010801],,,76.8,,6461.74,0.518595,35041.66656,percent of total billed charges,
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,AETNA [1000108],AETNA [100010801],,,76.8,,1090.81,0.518595,35041.66656,percent of total billed charges,
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,AETNA [1000108],AETNA [100010801],,,76.8,,1282.5,0.518595,35041.66656,percent of total billed charges,
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,AETNA [1000108],AETNA [100010801],,,76.8,,854.45,0.518595,35041.66656,percent of total billed charges,
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,AETNA [1000108],AETNA [100010801],,,76.8,,3479.45,0.518595,35041.66656,percent of total billed charges,
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,AETNA [1000108],AETNA [100010801],,,76.8,,3479.45,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,AETNA [1000108],AETNA [100010801],,,76.8,,3968.63,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,AETNA [1000108],AETNA [100010801],,,76.8,,3968.63,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,AETNA [1000108],AETNA [100010801],,,76.8,,3638.78,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,AETNA [1000108],AETNA [100010801],,,76.8,,4173.33,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,AETNA [1000108],AETNA [100010801],,,76.8,,2438.18,0.518595,35041.66656,percent of total billed charges,
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,AETNA [1000108],AETNA [100010801],,,76.8,,106.79,0.518595,35041.66656,percent of total billed charges,
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA [1000108],AETNA [100010801],,,76.8,,2742.49,0.518595,35041.66656,percent of total billed charges,
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,AETNA [1000108],AETNA [100010801],,,76.8,,331.17,0.518595,35041.66656,percent of total billed charges,
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,AETNA [1000108],AETNA [100010801],,,76.8,,396.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA [1000108],AETNA [100010801],,,76.8,,1237.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA [1000108],AETNA [100010801],,,76.8,,1237.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA [1000108],AETNA [100010801],,,76.8,,1237.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA [1000108],AETNA [100010801],,,76.8,,1237.76,0.518595,35041.66656,percent of total billed charges,
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,AETNA [1000108],AETNA [100010801],,,76.8,,96.8,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,AETNA [1000108],AETNA [100010801],,,76.8,,3655.1,0.518595,35041.66656,percent of total billed charges,
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,AETNA [1000108],AETNA [100010801],,,76.8,,2700.88,0.518595,35041.66656,percent of total billed charges,
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,AETNA [1000108],AETNA [100010801],,,76.8,,1424.61,0.518595,35041.66656,percent of total billed charges,
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,AETNA [1000108],AETNA [100010801],,,76.8,,576.74,0.518595,35041.66656,percent of total billed charges,
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,AETNA [1000108],AETNA [100010801],,,76.8,,576.74,0.518595,35041.66656,percent of total billed charges,
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,AETNA [1000108],AETNA [100010801],,,76.8,,1381.22,0.518595,35041.66656,percent of total billed charges,
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,AETNA [1000108],AETNA [100010801],,,76.8,,153.26,0.518595,35041.66656,percent of total billed charges,
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,AETNA [1000108],AETNA [100010801],,,76.8,,629.17,0.518595,35041.66656,percent of total billed charges,
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,AETNA [1000108],AETNA [100010801],,,76.8,,169.39,0.518595,35041.66656,percent of total billed charges,
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,AETNA [1000108],AETNA [100010801],,,76.8,,274.25,0.518595,35041.66656,percent of total billed charges,
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,AETNA [1000108],AETNA [100010801],,,76.8,,8343.45,0.518595,35041.66656,percent of total billed charges,
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,AETNA [1000108],AETNA [100010801],,,76.8,,7571.24,0.518595,35041.66656,percent of total billed charges,
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,AETNA [1000108],AETNA [100010801],,,76.8,,7155.19,0.518595,35041.66656,percent of total billed charges,
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,AETNA [1000108],AETNA [100010801],,,76.8,,653.37,0.518595,35041.66656,percent of total billed charges,
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,AETNA [1000108],AETNA [100010801],,,76.8,,681.6,0.518595,35041.66656,percent of total billed charges,
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,AETNA [1000108],AETNA [100010801],,,76.8,,1182.04,0.518595,35041.66656,percent of total billed charges,
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,AETNA [1000108],AETNA [100010801],,,76.8,,7317.34,0.518595,35041.66656,percent of total billed charges,
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,AETNA [1000108],AETNA [100010801],,,76.8,,786.46,0.518595,35041.66656,percent of total billed charges,
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,AETNA [1000108],AETNA [100010801],,,76.8,,7422.67,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA [1000108],AETNA [100010801],,,76.8,,286.44,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA [1000108],AETNA [100010801],,,76.8,,286.44,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA [1000108],AETNA [100010801],,,76.8,,286.44,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,AETNA [1000108],AETNA [100010801],,,76.8,,320.68,0.518595,35041.66656,percent of total billed charges,
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,AETNA [1000108],AETNA [100010801],,,76.8,,522.52,0.518595,35041.66656,percent of total billed charges,
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA [1000108],AETNA [100010801],,,76.8,,243.69,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA [1000108],AETNA [100010801],,,76.8,,243.69,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA [1000108],AETNA [100010801],,,76.8,,243.69,0.518595,35041.66656,percent of total billed charges,
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,AETNA [1000108],AETNA [100010801],,,76.8,,339.28,0.518595,35041.66656,percent of total billed charges,
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,AETNA [1000108],AETNA [100010801],,,76.8,,319.56,0.518595,35041.66656,percent of total billed charges,
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,AETNA [1000108],AETNA [100010801],,,76.8,,319.56,0.518595,35041.66656,percent of total billed charges,
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,AETNA [1000108],AETNA [100010801],,,76.8,,493.57,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,AETNA [1000108],AETNA [100010801],,,76.8,,273.63,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,AETNA [1000108],AETNA [100010801],,,76.8,,273.63,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,AETNA [1000108],AETNA [100010801],,,76.8,,267.76,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA [1000108],AETNA [100010801],,,76.8,,230.88,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA [1000108],AETNA [100010801],,,76.8,,230.88,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA [1000108],AETNA [100010801],,,76.8,,230.88,0.518595,35041.66656,percent of total billed charges,
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA [1000108],AETNA [100010801],,,76.8,,423.21,0.518595,35041.66656,percent of total billed charges,
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA [1000108],AETNA [100010801],,,76.8,,423.21,0.518595,35041.66656,percent of total billed charges,
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA [1000108],AETNA [100010801],,,76.8,,423.21,0.518595,35041.66656,percent of total billed charges,
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,AETNA [1000108],AETNA [100010801],,,76.8,,638.18,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA [1000108],AETNA [100010801],,,76.8,,350.25,0.518595,35041.66656,percent of total billed charges,
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,AETNA [1000108],AETNA [100010801],,,76.8,,282.19,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA [1000108],AETNA [100010801],,,76.8,,350.25,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA [1000108],AETNA [100010801],,,76.8,,350.25,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA [1000108],AETNA [100010801],,,76.8,,350.25,0.518595,35041.66656,percent of total billed charges,
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,AETNA [1000108],AETNA [100010801],,,76.8,,454.49,0.518595,35041.66656,percent of total billed charges,
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,AETNA [1000108],AETNA [100010801],,,76.8,,13.17,0.518595,35041.66656,percent of total billed charges,
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,AETNA [1000108],AETNA [100010801],,,76.8,,319.65,0.518595,35041.66656,percent of total billed charges,
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,AETNA [1000108],AETNA [100010801],,,76.8,,544.12,0.518595,35041.66656,percent of total billed charges,
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,AETNA [1000108],AETNA [100010801],,,76.8,,845.42,0.518595,35041.66656,percent of total billed charges,
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA [1000108],AETNA [100010801],,,76.8,,402.37,0.518595,35041.66656,percent of total billed charges,
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA [1000108],AETNA [100010801],,,76.8,,402.37,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,AETNA [1000108],AETNA [100010801],,,76.8,,253.28,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA [1000108],AETNA [100010801],,,76.8,,402.37,0.518595,35041.66656,percent of total billed charges,
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA [1000108],AETNA [100010801],,,76.8,,311.18,0.518595,35041.66656,percent of total billed charges,
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA [1000108],AETNA [100010801],,,76.8,,311.18,0.518595,35041.66656,percent of total billed charges,
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA [1000108],AETNA [100010801],,,76.8,,311.18,0.518595,35041.66656,percent of total billed charges,
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA [1000108],AETNA [100010801],,,76.8,,311.18,0.518595,35041.66656,percent of total billed charges,
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA [1000108],AETNA [100010801],,,76.8,,402.37,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,AETNA [1000108],AETNA [100010801],,,76.8,,479.09,0.518595,35041.66656,percent of total billed charges,
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA [1000108],AETNA [100010801],,,76.8,,354.02,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,AETNA [1000108],AETNA [100010801],,,76.8,,228.68,0.518595,35041.66656,percent of total billed charges,
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,AETNA [1000108],AETNA [100010801],,,76.8,,222.9,0.518595,35041.66656,percent of total billed charges,
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,AETNA [1000108],AETNA [100010801],,,76.8,,266.32,0.518595,35041.66656,percent of total billed charges,
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,AETNA [1000108],AETNA [100010801],,,76.8,,266.32,0.518595,35041.66656,percent of total billed charges,
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,0.518595,35041.66656,percent of total billed charges,
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,AETNA [1000108],AETNA [100010801],,,76.8,,8782.88,0.518595,35041.66656,percent of total billed charges,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,AETNA [1000108],AETNA [100010801],,,76.8,,542.15,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,AETNA [1000108],AETNA [100010801],,,76.8,,648.94,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,AETNA [1000108],AETNA [100010801],,,76.8,,807.08,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,AETNA [1000108],AETNA [100010801],,,76.8,,1108.76,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,AETNA [1000108],AETNA [100010801],,,76.8,,539.46,0.518595,35041.66656,percent of total billed charges,
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA [1000108],AETNA [100010801],,,76.8,,930.7,0.518595,35041.66656,percent of total billed charges,
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA [1000108],AETNA [100010801],,,76.8,,930.7,0.518595,35041.66656,percent of total billed charges,
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA [1000108],AETNA [100010801],,,76.8,,930.7,0.518595,35041.66656,percent of total billed charges,
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,AETNA [1000108],AETNA [100010801],,,76.8,,1027.63,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,AETNA [1000108],AETNA [100010801],,,76.8,,1022.5,0.518595,35041.66656,percent of total billed charges,
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,AETNA [1000108],AETNA [100010801],,,76.8,,1219.32,0.518595,35041.66656,percent of total billed charges,
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,AETNA [1000108],AETNA [100010801],,,76.8,,1342.79,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,AETNA [1000108],AETNA [100010801],,,76.8,,1032.39,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,AETNA [1000108],AETNA [100010801],,,76.8,,730.58,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,AETNA [1000108],AETNA [100010801],,,76.8,,458.75,0.518595,35041.66656,percent of total billed charges,
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,AETNA [1000108],AETNA [100010801],,,76.8,,612.95,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,AETNA [1000108],AETNA [100010801],,,76.8,,398.07,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,AETNA [1000108],AETNA [100010801],,,76.8,,338.56,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,AETNA [1000108],AETNA [100010801],,,76.8,,340.13,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,AETNA [1000108],AETNA [100010801],,,76.8,,2884.6,0.518595,35041.66656,percent of total billed charges,
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,AETNA [1000108],AETNA [100010801],,,76.8,,6606.79,0.518595,35041.66656,percent of total billed charges,
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,AETNA [1000108],AETNA [100010801],,,76.8,,4944.5,0.518595,35041.66656,percent of total billed charges,
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,AETNA [1000108],AETNA [100010801],,,76.8,,1586.84,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,AETNA [1000108],AETNA [100010801],,,76.8,,1245.66,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA [1000108],AETNA [100010801],,,76.8,,3196.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA [1000108],AETNA [100010801],,,76.8,,3196.47,0.518595,35041.66656,percent of total billed charges,
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA [1000108],AETNA [100010801],,,76.8,,3196.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA [1000108],AETNA [100010801],,,76.8,,3196.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,AETNA [1000108],AETNA [100010801],,,76.8,,3279.41,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA [1000108],AETNA [100010801],,,76.8,,3136.93,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA [1000108],AETNA [100010801],,,76.8,,3622.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA [1000108],AETNA [100010801],,,76.8,,3136.93,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA [1000108],AETNA [100010801],,,76.8,,3622.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA [1000108],AETNA [100010801],,,76.8,,3136.93,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA [1000108],AETNA [100010801],,,76.8,,3622.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA [1000108],AETNA [100010801],,,76.8,,3136.93,0.518595,35041.66656,percent of total billed charges,
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA [1000108],AETNA [100010801],,,76.8,,3622.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA [1000108],AETNA [100010801],,,76.8,,2649.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA [1000108],AETNA [100010801],,,76.8,,2649.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA [1000108],AETNA [100010801],,,76.8,,2649.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA [1000108],AETNA [100010801],,,76.8,,5447.49,0.518595,35041.66656,percent of total billed charges,
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA [1000108],AETNA [100010801],,,76.8,,5447.49,0.518595,35041.66656,percent of total billed charges,
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA [1000108],AETNA [100010801],,,76.8,,4764.35,0.518595,35041.66656,percent of total billed charges,
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA [1000108],AETNA [100010801],,,76.8,,5447.49,0.518595,35041.66656,percent of total billed charges,
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA [1000108],AETNA [100010801],,,76.8,,4764.35,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA [1000108],AETNA [100010801],,,76.8,,4764.35,0.518595,35041.66656,percent of total billed charges,
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,AETNA [1000108],AETNA [100010801],,,76.8,,3431.75,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,AETNA [1000108],AETNA [100010801],,,76.8,,3431.75,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,AETNA [1000108],AETNA [100010801],,,76.8,,788.71,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA [1000108],AETNA [100010801],,,76.8,,883.36,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA [1000108],AETNA [100010801],,,76.8,,822.3,0.518595,35041.66656,percent of total billed charges,
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,AETNA [1000108],AETNA [100010801],,,76.8,,1330.05,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,AETNA [1000108],AETNA [100010801],,,76.8,,2003.15,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,AETNA [1000108],AETNA [100010801],,,76.8,,915.85,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,AETNA [1000108],AETNA [100010801],,,76.8,,1648.54,0.518595,35041.66656,percent of total billed charges,
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,AETNA [1000108],AETNA [100010801],,,76.8,,866.59,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,AETNA [1000108],AETNA [100010801],,,76.8,,1920,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,AETNA [1000108],AETNA [100010801],,,76.8,,1895.43,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,AETNA [1000108],AETNA [100010801],,,76.8,,1962.12,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,AETNA [1000108],AETNA [100010801],,,76.8,,814.53,0.518595,35041.66656,percent of total billed charges,
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,AETNA [1000108],AETNA [100010801],,,76.8,,964.53,0.518595,35041.66656,percent of total billed charges,
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,AETNA [1000108],AETNA [100010801],,,76.8,,1067.85,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,AETNA [1000108],AETNA [100010801],,,76.8,,1067.11,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,AETNA [1000108],AETNA [100010801],,,76.8,,861.26,0.518595,35041.66656,percent of total billed charges,
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,AETNA [1000108],AETNA [100010801],,,76.8,,1547.14,0.518595,35041.66656,percent of total billed charges,
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,AETNA [1000108],AETNA [100010801],,,76.8,,3306.5,0.518595,35041.66656,percent of total billed charges,
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,AETNA [1000108],AETNA [100010801],,,76.8,,785.07,0.518595,35041.66656,percent of total billed charges,
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,AETNA [1000108],AETNA [100010801],,,76.8,,501.95,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,AETNA [1000108],AETNA [100010801],,,76.8,,1013.26,0.518595,35041.66656,percent of total billed charges,
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,AETNA [1000108],AETNA [100010801],,,76.8,,1940.79,0.518595,35041.66656,percent of total billed charges,
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,AETNA [1000108],AETNA [100010801],,,76.8,,927.53,0.518595,35041.66656,percent of total billed charges,
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,AETNA [1000108],AETNA [100010801],,,76.8,,1067.85,0.518595,35041.66656,percent of total billed charges,
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,AETNA [1000108],AETNA [100010801],,,76.8,,617.74,0.518595,35041.66656,percent of total billed charges,
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,AETNA [1000108],AETNA [100010801],,,76.8,,845.17,0.518595,35041.66656,percent of total billed charges,
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,AETNA [1000108],AETNA [100010801],,,76.8,,870.89,0.518595,35041.66656,percent of total billed charges,
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,AETNA [1000108],AETNA [100010801],,,76.8,,394.67,0.518595,35041.66656,percent of total billed charges,
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,AETNA [1000108],AETNA [100010801],,,76.8,,915.85,0.518595,35041.66656,percent of total billed charges,
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,0.518595,35041.66656,percent of total billed charges,
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,AETNA [1000108],AETNA [100010801],,,76.8,,1473.09,0.518595,35041.66656,percent of total billed charges,
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,AETNA [1000108],AETNA [100010801],,,76.8,,1874.56,0.518595,35041.66656,percent of total billed charges,
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,0.518595,35041.66656,percent of total billed charges,
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,AETNA [1000108],AETNA [100010801],,,76.8,,559.49,0.518595,35041.66656,percent of total billed charges,
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA [1000108],AETNA [100010801],,,76.8,,1872.56,0.518595,35041.66656,percent of total billed charges,
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA [1000108],AETNA [100010801],,,76.8,,1872.56,0.518595,35041.66656,percent of total billed charges,
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA [1000108],AETNA [100010801],,,76.8,,1872.56,0.518595,35041.66656,percent of total billed charges,
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,AETNA [1000108],AETNA [100010801],,,76.8,,3512.44,0.518595,35041.66656,percent of total billed charges,
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,76.8,,1506.19,0.518595,35041.66656,percent of total billed charges,
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA [1000108],AETNA [100010801],,,76.8,,440.95,0.518595,35041.66656,percent of total billed charges,
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA [1000108],AETNA [100010801],,,76.8,,440.95,0.518595,35041.66656,percent of total billed charges,
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,AETNA [1000108],AETNA [100010801],,,76.8,,488.73,0.518595,35041.66656,percent of total billed charges,
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,AETNA [1000108],AETNA [100010801],,,76.8,,488.73,0.518595,35041.66656,percent of total billed charges,
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,AETNA [1000108],AETNA [100010801],,,76.8,,455.65,0.518595,35041.66656,percent of total billed charges,
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA [1000108],AETNA [100010801],,,76.8,,440.95,0.518595,35041.66656,percent of total billed charges,
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA [1000108],AETNA [100010801],,,76.8,,440.95,0.518595,35041.66656,percent of total billed charges,
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,AETNA [1000108],AETNA [100010801],,,76.8,,5387.61,0.518595,35041.66656,percent of total billed charges,
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,AETNA [1000108],AETNA [100010801],,,76.8,,789.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA [1000108],AETNA [100010801],,,76.8,,1004.47,0.518595,35041.66656,percent of total billed charges,
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA [1000108],AETNA [100010801],,,76.8,,1004.47,0.518595,35041.66656,percent of total billed charges,
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA [1000108],AETNA [100010801],,,76.8,,1004.47,0.518595,35041.66656,percent of total billed charges,
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA [1000108],AETNA [100010801],,,76.8,,1887.48,0.518595,35041.66656,percent of total billed charges,
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA [1000108],AETNA [100010801],,,76.8,,1887.48,0.518595,35041.66656,percent of total billed charges,
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA [1000108],AETNA [100010801],,,76.8,,1887.48,0.518595,35041.66656,percent of total billed charges,
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,AETNA [1000108],AETNA [100010801],,,76.8,,1839.96,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,AETNA [1000108],AETNA [100010801],,,76.8,,2243.86,0.518595,35041.66656,percent of total billed charges,
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,AETNA [1000108],AETNA [100010801],,,76.8,,2243.86,0.518595,35041.66656,percent of total billed charges,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,AETNA [1000108],AETNA [100010801],,,76.8,,860.97,0.518595,35041.66656,percent of total billed charges,
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA [1000108],AETNA [100010801],,,76.8,,853.85,0.518595,35041.66656,percent of total billed charges,
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA [1000108],AETNA [100010801],,,76.8,,853.85,0.518595,35041.66656,percent of total billed charges,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA [1000108],AETNA [100010801],,,76.8,,853.85,0.518595,35041.66656,percent of total billed charges,
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA [1000108],AETNA [100010801],,,76.8,,853.85,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,AETNA [1000108],AETNA [100010801],,,76.8,,4449.07,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,AETNA [1000108],AETNA [100010801],,,76.8,,3875.42,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA [1000108],AETNA [100010801],,,76.8,,116.15,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA [1000108],AETNA [100010801],,,76.8,,116.15,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA [1000108],AETNA [100010801],,,76.8,,274.39,0.518595,35041.66656,percent of total billed charges,
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA [1000108],AETNA [100010801],,,76.8,,274.39,0.518595,35041.66656,percent of total billed charges,
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA [1000108],AETNA [100010801],,,76.8,,274.39,0.518595,35041.66656,percent of total billed charges,
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA [1000108],AETNA [100010801],,,76.8,,274.39,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA [1000108],AETNA [100010801],,,76.8,,116.15,0.518595,35041.66656,percent of total billed charges,
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,AETNA [1000108],AETNA [100010801],,,76.8,,252.74,0.518595,35041.66656,percent of total billed charges,
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,AETNA [1000108],AETNA [100010801],,,76.8,,2163.56,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,AETNA [1000108],AETNA [100010801],,,76.8,,1896.98,0.518595,35041.66656,percent of total billed charges,
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA [1000108],AETNA [100010801],,,76.8,,10978.6,0.518595,35041.66656,percent of total billed charges,
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA [1000108],AETNA [100010801],,,76.8,,10978.6,0.518595,35041.66656,percent of total billed charges,
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,76.8,,304.73,0.518595,35041.66656,percent of total billed charges,
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA [1000108],AETNA [100010801],,,76.8,,89.13,0.518595,35041.66656,percent of total billed charges,
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA [1000108],AETNA [100010801],,,76.8,,89.13,0.518595,35041.66656,percent of total billed charges,
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA [1000108],AETNA [100010801],,,76.8,,89.13,0.518595,35041.66656,percent of total billed charges,
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,AETNA [1000108],AETNA [100010801],,,76.8,,234.1,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,76.8,,331.61,0.518595,35041.66656,percent of total billed charges,
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,76.8,,331.61,0.518595,35041.66656,percent of total billed charges,
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,AETNA [1000108],AETNA [100010801],,,76.8,,121,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,76.8,,94.11,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,AETNA [1000108],AETNA [100010801],,,76.8,,118,0.518595,35041.66656,percent of total billed charges,
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,AETNA [1000108],AETNA [100010801],,,76.8,,97.47,0.518595,35041.66656,percent of total billed charges,
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,AETNA [1000108],AETNA [100010801],,,76.8,,95.54,0.518595,35041.66656,percent of total billed charges,
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,76.8,,677.57,0.518595,35041.66656,percent of total billed charges,
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,0.518595,35041.66656,percent of total billed charges,
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,0.518595,35041.66656,percent of total billed charges,
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,AETNA [1000108],AETNA [100010801],,,76.8,,20639.76,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,AETNA [1000108],AETNA [100010801],,,76.8,,5981.31,0.518595,35041.66656,percent of total billed charges,
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA [1000108],AETNA [100010801],,,76.8,,5684.38,0.518595,35041.66656,percent of total billed charges,
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA [1000108],AETNA [100010801],,,76.8,,5684.38,0.518595,35041.66656,percent of total billed charges,
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,0.518595,35041.66656,percent of total billed charges,
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,AETNA [1000108],AETNA [100010801],,,76.8,,1169.99,0.518595,35041.66656,percent of total billed charges,
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,AETNA [1000108],AETNA [100010801],,,76.8,,1692.39,0.518595,35041.66656,percent of total billed charges,
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,AETNA [1000108],AETNA [100010801],,,76.8,,1692.39,0.518595,35041.66656,percent of total billed charges,
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,AETNA [1000108],AETNA [100010801],,,76.8,,2109.04,0.518595,35041.66656,percent of total billed charges,
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,AETNA [1000108],AETNA [100010801],,,76.8,,3306.61,0.518595,35041.66656,percent of total billed charges,
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,AETNA [1000108],AETNA [100010801],,,76.8,,3215.61,0.518595,35041.66656,percent of total billed charges,
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,AETNA [1000108],AETNA [100010801],,,76.8,,3030.71,0.518595,35041.66656,percent of total billed charges,
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA [1000108],AETNA [100010801],,,76.8,,4488.18,0.518595,35041.66656,percent of total billed charges,
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA [1000108],AETNA [100010801],,,76.8,,4488.18,0.518595,35041.66656,percent of total billed charges,
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA [1000108],AETNA [100010801],,,76.8,,4488.18,0.518595,35041.66656,percent of total billed charges,
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA [1000108],AETNA [100010801],,,76.8,,4916.47,0.518595,35041.66656,percent of total billed charges,
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA [1000108],AETNA [100010801],,,76.8,,4916.47,0.518595,35041.66656,percent of total billed charges,
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA [1000108],AETNA [100010801],,,76.8,,4916.47,0.518595,35041.66656,percent of total billed charges,
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA [1000108],AETNA [100010801],,,76.8,,4916.47,0.518595,35041.66656,percent of total billed charges,
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,AETNA [1000108],AETNA [100010801],,,76.8,,6755.74,0.518595,35041.66656,percent of total billed charges,
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA [1000108],AETNA [100010801],,,76.8,,7006.55,0.518595,35041.66656,percent of total billed charges,
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,AETNA [1000108],AETNA [100010801],,,76.8,,7318.96,0.518595,35041.66656,percent of total billed charges,
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,AETNA [1000108],AETNA [100010801],,,76.8,,7792.72,0.518595,35041.66656,percent of total billed charges,
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,AETNA [1000108],AETNA [100010801],,,76.8,,6755.74,0.518595,35041.66656,percent of total billed charges,
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA [1000108],AETNA [100010801],,,76.8,,7006.55,0.518595,35041.66656,percent of total billed charges,
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA [1000108],AETNA [100010801],,,76.8,,7006.55,0.518595,35041.66656,percent of total billed charges,
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,AETNA [1000108],AETNA [100010801],,,76.8,,7318.96,0.518595,35041.66656,percent of total billed charges,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,AETNA [1000108],AETNA [100010801],,,76.8,,7792.72,0.518595,35041.66656,percent of total billed charges,
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,AETNA [1000108],AETNA [100010801],,,76.8,,5535.43,0.518595,35041.66656,percent of total billed charges,
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,AETNA [1000108],AETNA [100010801],,,76.8,,5649.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,AETNA [1000108],AETNA [100010801],,,76.8,,5767.17,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,AETNA [1000108],AETNA [100010801],,,76.8,,5881.57,0.518595,35041.66656,percent of total billed charges,
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,AETNA [1000108],AETNA [100010801],,,76.8,,6220.39,0.518595,35041.66656,percent of total billed charges,
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,AETNA [1000108],AETNA [100010801],,,76.8,,6462.4,0.518595,35041.66656,percent of total billed charges,
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,AETNA [1000108],AETNA [100010801],,,76.8,,5535.43,0.518595,35041.66656,percent of total billed charges,
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,AETNA [1000108],AETNA [100010801],,,76.8,,5649.83,0.518595,35041.66656,percent of total billed charges,
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,AETNA [1000108],AETNA [100010801],,,76.8,,6825.72,0.518595,35041.66656,percent of total billed charges,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,AETNA [1000108],AETNA [100010801],,,76.8,,5881.57,0.518595,35041.66656,percent of total billed charges,
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,AETNA [1000108],AETNA [100010801],,,76.8,,6220.39,0.518595,35041.66656,percent of total billed charges,
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,AETNA [1000108],AETNA [100010801],,,76.8,,6337.73,0.518595,35041.66656,percent of total billed charges,
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,AETNA [1000108],AETNA [100010801],,,76.8,,6462.4,0.518595,35041.66656,percent of total billed charges,
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,AETNA [1000108],AETNA [100010801],,,76.8,,5454.76,0.518595,35041.66656,percent of total billed charges,
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,AETNA [1000108],AETNA [100010801],,,76.8,,6141.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,AETNA [1000108],AETNA [100010801],,,76.8,,6302.52,0.518595,35041.66656,percent of total billed charges,
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,AETNA [1000108],AETNA [100010801],,,76.8,,5299.28,0.518595,35041.66656,percent of total billed charges,
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,AETNA [1000108],AETNA [100010801],,,76.8,,5454.76,0.518595,35041.66656,percent of total billed charges,
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,AETNA [1000108],AETNA [100010801],,,76.8,,5610.23,0.518595,35041.66656,percent of total billed charges,
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,AETNA [1000108],AETNA [100010801],,,76.8,,5981.31,0.518595,35041.66656,percent of total billed charges,
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,AETNA [1000108],AETNA [100010801],,,76.8,,6141.18,0.518595,35041.66656,percent of total billed charges,
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,AETNA [1000108],AETNA [100010801],,,76.8,,6302.52,0.518595,35041.66656,percent of total billed charges,
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,AETNA [1000108],AETNA [100010801],,,76.8,,6502.23,0.518595,35041.66656,percent of total billed charges,
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,AETNA [1000108],AETNA [100010801],,,76.8,,5992.07,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,AETNA [1000108],AETNA [100010801],,,76.8,,6125.05,0.518595,35041.66656,percent of total billed charges,
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,AETNA [1000108],AETNA [100010801],,,76.8,,6428.57,0.518595,35041.66656,percent of total billed charges,
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,AETNA [1000108],AETNA [100010801],,,76.8,,6700.78,0.518595,35041.66656,percent of total billed charges,
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,AETNA [1000108],AETNA [100010801],,,76.8,,5860.65,0.518595,35041.66656,percent of total billed charges,
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,AETNA [1000108],AETNA [100010801],,,76.8,,5992.07,0.518595,35041.66656,percent of total billed charges,
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,AETNA [1000108],AETNA [100010801],,,76.8,,6125.05,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,AETNA [1000108],AETNA [100010801],,,76.8,,6428.57,0.518595,35041.66656,percent of total billed charges,
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,AETNA [1000108],AETNA [100010801],,,76.8,,4337.11,0.518595,35041.66656,percent of total billed charges,
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,AETNA [1000108],AETNA [100010801],,,76.8,,4337.11,0.518595,35041.66656,percent of total billed charges,
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,AETNA [1000108],AETNA [100010801],,,76.8,,4461.78,0.518595,35041.66656,percent of total billed charges,
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,AETNA [1000108],AETNA [100010801],,,76.8,,4684.72,0.518595,35041.66656,percent of total billed charges,
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,AETNA [1000108],AETNA [100010801],,,76.8,,5083.68,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA [1000108],AETNA [100010801],,,76.8,,5443.02,0.518595,35041.66656,percent of total billed charges,
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA [1000108],AETNA [100010801],,,76.8,,5443.02,0.518595,35041.66656,percent of total billed charges,
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA [1000108],AETNA [100010801],,,76.8,,5643.96,0.518595,35041.66656,percent of total billed charges,
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA [1000108],AETNA [100010801],,,76.8,,5443.02,0.518595,35041.66656,percent of total billed charges,
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA [1000108],AETNA [100010801],,,76.8,,5643.96,0.518595,35041.66656,percent of total billed charges,
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA [1000108],AETNA [100010801],,,76.8,,5643.96,0.518595,35041.66656,percent of total billed charges,
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,AETNA [1000108],AETNA [100010801],,,76.8,,5774.5,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,AETNA [1000108],AETNA [100010801],,,76.8,,5774.5,0.518595,35041.66656,percent of total billed charges,
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,AETNA [1000108],AETNA [100010801],,,76.8,,6009.02,0.518595,35041.66656,percent of total billed charges,
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,AETNA [1000108],AETNA [100010801],,,76.8,,7165.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,AETNA [1000108],AETNA [100010801],,,76.8,,6289.32,0.518595,35041.66656,percent of total billed charges,
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA [1000108],AETNA [100010801],,,76.8,,6668.71,0.518595,35041.66656,percent of total billed charges,
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,AETNA [1000108],AETNA [100010801],,,76.8,,6813.43,0.518595,35041.66656,percent of total billed charges,
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,AETNA [1000108],AETNA [100010801],,,76.8,,7104.17,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,AETNA [1000108],AETNA [100010801],,,76.8,,7390.99,0.518595,35041.66656,percent of total billed charges,
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,AETNA [1000108],AETNA [100010801],,,76.8,,6009.02,0.518595,35041.66656,percent of total billed charges,
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,AETNA [1000108],AETNA [100010801],,,76.8,,6151.13,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,AETNA [1000108],AETNA [100010801],,,76.8,,6289.32,0.518595,35041.66656,percent of total billed charges,
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA [1000108],AETNA [100010801],,,76.8,,6668.71,0.518595,35041.66656,percent of total billed charges,
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,AETNA [1000108],AETNA [100010801],,,76.8,,6813.43,0.518595,35041.66656,percent of total billed charges,
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,AETNA [1000108],AETNA [100010801],,,76.8,,7104.17,0.518595,35041.66656,percent of total billed charges,
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,AETNA [1000108],AETNA [100010801],,,76.8,,7390.99,0.518595,35041.66656,percent of total billed charges,
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,AETNA [1000108],AETNA [100010801],,,76.8,,4879.8,0.518595,35041.66656,percent of total billed charges,
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,AETNA [1000108],AETNA [100010801],,,76.8,,5038.2,0.518595,35041.66656,percent of total billed charges,
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA [1000108],AETNA [100010801],,,76.8,,5195.14,0.518595,35041.66656,percent of total billed charges,
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,AETNA [1000108],AETNA [100010801],,,76.8,,5350.62,0.518595,35041.66656,percent of total billed charges,
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,AETNA [1000108],AETNA [100010801],,,76.8,,6041.45,0.518595,35041.66656,percent of total billed charges,
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,AETNA [1000108],AETNA [100010801],,,76.8,,6358.26,0.518595,35041.66656,percent of total billed charges,
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,AETNA [1000108],AETNA [100010801],,,76.8,,4879.8,0.518595,35041.66656,percent of total billed charges,
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,AETNA [1000108],AETNA [100010801],,,76.8,,5038.2,0.518595,35041.66656,percent of total billed charges,
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA [1000108],AETNA [100010801],,,76.8,,5195.14,0.518595,35041.66656,percent of total billed charges,
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA [1000108],AETNA [100010801],,,76.8,,5195.14,0.518595,35041.66656,percent of total billed charges,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,AETNA [1000108],AETNA [100010801],,,76.8,,6334.07,0.518595,35041.66656,percent of total billed charges,
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,AETNA [1000108],AETNA [100010801],,,76.8,,5712.9,0.518595,35041.66656,percent of total billed charges,
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,AETNA [1000108],AETNA [100010801],,,76.8,,5878.64,0.518595,35041.66656,percent of total billed charges,
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,AETNA [1000108],AETNA [100010801],,,76.8,,21360.81,0.518595,35041.66656,percent of total billed charges,
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,AETNA [1000108],AETNA [100010801],,,76.8,,15034.86,0.518595,35041.66656,percent of total billed charges,
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA [1000108],AETNA [100010801],,,76.8,,2961.38,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA [1000108],AETNA [100010801],,,76.8,,2961.38,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA [1000108],AETNA [100010801],,,76.8,,2961.38,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,AETNA [1000108],AETNA [100010801],,,76.8,,3608.15,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,AETNA [1000108],AETNA [100010801],,,76.8,,3608.15,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,AETNA [1000108],AETNA [100010801],,,76.8,,3440.91,0.518595,35041.66656,percent of total billed charges,
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,AETNA [1000108],AETNA [100010801],,,76.8,,3440.91,0.518595,35041.66656,percent of total billed charges,
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,AETNA [1000108],AETNA [100010801],,,76.8,,990.67,0.518595,35041.66656,percent of total billed charges,
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA [1000108],AETNA [100010801],,,76.8,,2066.22,0.518595,35041.66656,percent of total billed charges,
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA [1000108],AETNA [100010801],,,76.8,,2066.22,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,AETNA [1000108],AETNA [100010801],,,76.8,,1927.35,0.518595,35041.66656,percent of total billed charges,
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA [1000108],AETNA [100010801],,,76.8,,2066.22,0.518595,35041.66656,percent of total billed charges,
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA [1000108],AETNA [100010801],,,76.8,,2066.22,0.518595,35041.66656,percent of total billed charges,
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA [1000108],AETNA [100010801],,,76.8,,6637.1,0.518595,35041.66656,percent of total billed charges,
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA [1000108],AETNA [100010801],,,76.8,,1493.16,0.518595,35041.66656,percent of total billed charges,
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA [1000108],AETNA [100010801],,,76.8,,1493.16,0.518595,35041.66656,percent of total billed charges,
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA [1000108],AETNA [100010801],,,76.8,,1493.16,0.518595,35041.66656,percent of total billed charges,
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA [1000108],AETNA [100010801],,,76.8,,1690.19,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA [1000108],AETNA [100010801],,,76.8,,1910.95,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA [1000108],AETNA [100010801],,,76.8,,1910.95,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA [1000108],AETNA [100010801],,,76.8,,1910.95,0.518595,35041.66656,percent of total billed charges,
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA [1000108],AETNA [100010801],,,76.8,,2088.4,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA [1000108],AETNA [100010801],,,76.8,,2088.4,0.518595,35041.66656,percent of total billed charges,
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA [1000108],AETNA [100010801],,,76.8,,1690.19,0.518595,35041.66656,percent of total billed charges,
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA [1000108],AETNA [100010801],,,76.8,,1690.19,0.518595,35041.66656,percent of total billed charges,
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA [1000108],AETNA [100010801],,,76.8,,1690.19,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA [1000108],AETNA [100010801],,,76.8,,2265.85,0.518595,35041.66656,percent of total billed charges,
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA [1000108],AETNA [100010801],,,76.8,,2265.85,0.518595,35041.66656,percent of total billed charges,
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA [1000108],AETNA [100010801],,,76.8,,2265.85,0.518595,35041.66656,percent of total billed charges,
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA [1000108],AETNA [100010801],,,76.8,,2265.85,0.518595,35041.66656,percent of total billed charges,
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,AETNA [1000108],AETNA [100010801],,,76.8,,2972.74,0.518595,35041.66656,percent of total billed charges,
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA [1000108],AETNA [100010801],,,76.8,,2088.4,0.518595,35041.66656,percent of total billed charges,
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,AETNA [1000108],AETNA [100010801],,,76.8,,2086.2,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA [1000108],AETNA [100010801],,,76.8,,2088.4,0.518595,35041.66656,percent of total billed charges,
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,AETNA [1000108],AETNA [100010801],,,76.8,,3151.66,0.518595,35041.66656,percent of total billed charges,
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,AETNA [1000108],AETNA [100010801],,,76.8,,3151.66,0.518595,35041.66656,percent of total billed charges,
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,AETNA [1000108],AETNA [100010801],,,76.8,,7973.12,0.518595,35041.66656,percent of total billed charges,
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,AETNA [1000108],AETNA [100010801],,,76.8,,7973.12,0.518595,35041.66656,percent of total billed charges,
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,AETNA [1000108],AETNA [100010801],,,76.8,,5400.42,0.518595,35041.66656,percent of total billed charges,
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,AETNA [1000108],AETNA [100010801],,,76.8,,1699.96,0.518595,35041.66656,percent of total billed charges,
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,AETNA [1000108],AETNA [100010801],,,76.8,,251.4,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA [1000108],AETNA [100010801],,,76.8,,883.36,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,AETNA [1000108],AETNA [100010801],,,76.8,,533.72,0.518595,35041.66656,percent of total billed charges,
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,AETNA [1000108],AETNA [100010801],,,76.8,,533.72,0.518595,35041.66656,percent of total billed charges,
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,AETNA [1000108],AETNA [100010801],,,76.8,,1844.88,0.518595,35041.66656,percent of total billed charges,
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,AETNA [1000108],AETNA [100010801],,,76.8,,886.66,0.518595,35041.66656,percent of total billed charges,
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,AETNA [1000108],AETNA [100010801],,,76.8,,656.06,0.518595,35041.66656,percent of total billed charges,
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,AETNA [1000108],AETNA [100010801],,,76.8,,2020.41,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,AETNA [1000108],AETNA [100010801],,,76.8,,2020.41,0.518595,35041.66656,percent of total billed charges,
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,AETNA [1000108],AETNA [100010801],,,76.8,,184.31,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,AETNA [1000108],AETNA [100010801],,,76.8,,1434.95,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA [1000108],AETNA [100010801],,,76.8,,1614.8,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA [1000108],AETNA [100010801],,,76.8,,1614.8,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA [1000108],AETNA [100010801],,,76.8,,1614.8,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA [1000108],AETNA [100010801],,,76.8,,1614.8,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,AETNA [1000108],AETNA [100010801],,,76.8,,381.8,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,AETNA [1000108],AETNA [100010801],,,76.8,,381.8,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,AETNA [1000108],AETNA [100010801],,,76.8,,155.46,0.518595,35041.66656,percent of total billed charges,
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,AETNA [1000108],AETNA [100010801],,,76.8,,289.18,0.518595,35041.66656,percent of total billed charges,
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,AETNA [1000108],AETNA [100010801],,,76.8,,2983.93,0.518595,35041.66656,percent of total billed charges,
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,AETNA [1000108],AETNA [100010801],,,76.8,,383.15,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,AETNA [1000108],AETNA [100010801],,,76.8,,383.15,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,AETNA [1000108],AETNA [100010801],,,76.8,,5117.25,0.518595,35041.66656,percent of total billed charges,
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA [1000108],AETNA [100010801],,,76.8,,3019.08,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA [1000108],AETNA [100010801],,,76.8,,3019.08,0.518595,35041.66656,percent of total billed charges,
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA [1000108],AETNA [100010801],,,76.8,,3019.08,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,AETNA [1000108],AETNA [100010801],,,76.8,,3385.53,0.518595,35041.66656,percent of total billed charges,
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,AETNA [1000108],AETNA [100010801],,,76.8,,4411.91,0.518595,35041.66656,percent of total billed charges,
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,AETNA [1000108],AETNA [100010801],,,76.8,,3385.53,0.518595,35041.66656,percent of total billed charges,
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,AETNA [1000108],AETNA [100010801],,,76.8,,4411.91,0.518595,35041.66656,percent of total billed charges,
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,AETNA [1000108],AETNA [100010801],,,76.8,,1307.94,0.518595,35041.66656,percent of total billed charges,
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,AETNA [1000108],AETNA [100010801],,,76.8,,1231,0.518595,35041.66656,percent of total billed charges,
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA [1000108],AETNA [100010801],,,76.8,,4879.31,0.518595,35041.66656,percent of total billed charges,
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA [1000108],AETNA [100010801],,,76.8,,4879.31,0.518595,35041.66656,percent of total billed charges,
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,AETNA [1000108],AETNA [100010801],,,76.8,,5368.22,0.518595,35041.66656,percent of total billed charges,
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA [1000108],AETNA [100010801],,,76.8,,4879.31,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,AETNA [1000108],AETNA [100010801],,,76.8,,5019.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,AETNA [1000108],AETNA [100010801],,,76.8,,5694.16,0.518595,35041.66656,percent of total billed charges,
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,AETNA [1000108],AETNA [100010801],,,76.8,,5019.46,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,AETNA [1000108],AETNA [100010801],,,76.8,,387.9,0.518595,35041.66656,percent of total billed charges,
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,AETNA [1000108],AETNA [100010801],,,76.8,,873.1,0.518595,35041.66656,percent of total billed charges,
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,AETNA [1000108],AETNA [100010801],,,76.8,,429.4,0.518595,35041.66656,percent of total billed charges,
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,AETNA [1000108],AETNA [100010801],,,76.8,,466.05,0.518595,35041.66656,percent of total billed charges,
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,AETNA [1000108],AETNA [100010801],,,76.8,,1045.26,0.518595,35041.66656,percent of total billed charges,
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA [1000108],AETNA [100010801],,,76.8,,1488.65,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA [1000108],AETNA [100010801],,,76.8,,1488.65,0.518595,35041.66656,percent of total billed charges,
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA [1000108],AETNA [100010801],,,76.8,,1488.65,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,AETNA [1000108],AETNA [100010801],,,76.8,,3193.68,0.518595,35041.66656,percent of total billed charges,
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,AETNA [1000108],AETNA [100010801],,,76.8,,3572.62,0.518595,35041.66656,percent of total billed charges,
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,AETNA [1000108],AETNA [100010801],,,76.8,,3414.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,AETNA [1000108],AETNA [100010801],,,76.8,,3904.59,0.518595,35041.66656,percent of total billed charges,
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,AETNA [1000108],AETNA [100010801],,,76.8,,1804.54,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,AETNA [1000108],AETNA [100010801],,,76.8,,339.06,0.518595,35041.66656,percent of total billed charges,
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,AETNA [1000108],AETNA [100010801],,,76.8,,5453.78,0.518595,35041.66656,percent of total billed charges,
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,AETNA [1000108],AETNA [100010801],,,76.8,,118.76,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,AETNA [1000108],AETNA [100010801],,,76.8,,118.76,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,AETNA [1000108],AETNA [100010801],,,76.8,,276.23,0.518595,35041.66656,percent of total billed charges,
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,76.8,,622.9,0.518595,35041.66656,percent of total billed charges,
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,76.8,,622.9,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,AETNA [1000108],AETNA [100010801],,,76.8,,750.61,0.518595,35041.66656,percent of total billed charges,
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,AETNA [1000108],AETNA [100010801],,,76.8,,3471.45,0.518595,35041.66656,percent of total billed charges,
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA [1000108],AETNA [100010801],,,76.8,,1761.1,0.518595,35041.66656,percent of total billed charges,
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA [1000108],AETNA [100010801],,,76.8,,1761.1,0.518595,35041.66656,percent of total billed charges,
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA [1000108],AETNA [100010801],,,76.8,,1761.1,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,AETNA [1000108],AETNA [100010801],,,76.8,,1844.02,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,AETNA [1000108],AETNA [100010801],,,76.8,,11866.3,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,AETNA [1000108],AETNA [100010801],,,76.8,,11866.3,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,AETNA [1000108],AETNA [100010801],,,76.8,,10912.01,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,AETNA [1000108],AETNA [100010801],,,76.8,,1145.11,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA [1000108],AETNA [100010801],,,76.8,,1488.65,0.518595,35041.66656,percent of total billed charges,
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA [1000108],AETNA [100010801],,,76.8,,1508.39,0.518595,35041.66656,percent of total billed charges,
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA [1000108],AETNA [100010801],,,76.8,,1508.39,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA [1000108],AETNA [100010801],,,76.8,,1508.39,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA [1000108],AETNA [100010801],,,76.8,,1508.39,0.518595,35041.66656,percent of total billed charges,
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,AETNA [1000108],AETNA [100010801],,,76.8,,12447.17,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,AETNA [1000108],AETNA [100010801],,,76.8,,13249.31,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA [1000108],AETNA [100010801],,,76.8,,13498.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,AETNA [1000108],AETNA [100010801],,,76.8,,12447.17,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA [1000108],AETNA [100010801],,,76.8,,13498.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,AETNA [1000108],AETNA [100010801],,,76.8,,13318.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA [1000108],AETNA [100010801],,,76.8,,13498.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,AETNA [1000108],AETNA [100010801],,,76.8,,13097.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,AETNA [1000108],AETNA [100010801],,,76.8,,1433.36,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,AETNA [1000108],AETNA [100010801],,,76.8,,1433.36,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,AETNA [1000108],AETNA [100010801],,,76.8,,381,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,AETNA [1000108],AETNA [100010801],,,76.8,,9598.15,0.518595,35041.66656,percent of total billed charges,
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,AETNA [1000108],AETNA [100010801],,,76.8,,9805.6,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,AETNA [1000108],AETNA [100010801],,,76.8,,10386.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,AETNA [1000108],AETNA [100010801],,,76.8,,11921.62,0.518595,35041.66656,percent of total billed charges,
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA [1000108],AETNA [100010801],,,76.8,,11506.71,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA [1000108],AETNA [100010801],,,76.8,,11506.71,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,AETNA [1000108],AETNA [100010801],,,76.8,,11838.64,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,AETNA [1000108],AETNA [100010801],,,76.8,,9155.58,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,AETNA [1000108],AETNA [100010801],,,76.8,,1085.88,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA [1000108],AETNA [100010801],,,76.8,,11506.71,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,AETNA [1000108],AETNA [100010801],,,76.8,,9404.52,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,AETNA [1000108],AETNA [100010801],,,76.8,,11064.15,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,AETNA [1000108],AETNA [100010801],,,76.8,,11921.62,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,AETNA [1000108],AETNA [100010801],,,76.8,,469.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA [1000108],AETNA [100010801],,,76.8,,7919.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,AETNA [1000108],AETNA [100010801],,,76.8,,7343.82,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA [1000108],AETNA [100010801],,,76.8,,7919.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,AETNA [1000108],AETNA [100010801],,,76.8,,7343.82,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA [1000108],AETNA [100010801],,,76.8,,7919.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA [1000108],AETNA [100010801],,,76.8,,7919.83,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,AETNA [1000108],AETNA [100010801],,,76.8,,6781.66,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA [1000108],AETNA [100010801],,,76.8,,6939.73,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA [1000108],AETNA [100010801],,,76.8,,6939.73,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA [1000108],AETNA [100010801],,,76.8,,6939.73,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,AETNA [1000108],AETNA [100010801],,,76.8,,11064.15,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,AETNA [1000108],AETNA [100010801],,,76.8,,456.41,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,AETNA [1000108],AETNA [100010801],,,76.8,,456.41,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,AETNA [1000108],AETNA [100010801],,,76.8,,1477.69,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,AETNA [1000108],AETNA [100010801],,,76.8,,1520.23,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,AETNA [1000108],AETNA [100010801],,,76.8,,1998.02,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,AETNA [1000108],AETNA [100010801],,,76.8,,1998.02,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,AETNA [1000108],AETNA [100010801],,,76.8,,1945.37,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,AETNA [1000108],AETNA [100010801],,,76.8,,1840.07,0.518595,35041.66656,percent of total billed charges,
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,AETNA [1000108],AETNA [100010801],,,76.8,,1930.9,0.518595,35041.66656,percent of total billed charges,
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,AETNA [1000108],AETNA [100010801],,,76.8,,878.06,0.518595,35041.66656,percent of total billed charges,
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,AETNA [1000108],AETNA [100010801],,,76.8,,878.06,0.518595,35041.66656,percent of total billed charges,
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,AETNA [1000108],AETNA [100010801],,,76.8,,817.37,0.518595,35041.66656,percent of total billed charges,
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,AETNA [1000108],AETNA [100010801],,,76.8,,817.37,0.518595,35041.66656,percent of total billed charges,
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,AETNA [1000108],AETNA [100010801],,,76.8,,841.07,0.518595,35041.66656,percent of total billed charges,
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,AETNA [1000108],AETNA [100010801],,,76.8,,841.07,0.518595,35041.66656,percent of total billed charges,
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,AETNA [1000108],AETNA [100010801],,,76.8,,3604.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,AETNA [1000108],AETNA [100010801],,,76.8,,3952.01,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,AETNA [1000108],AETNA [100010801],,,76.8,,3478.2,0.518595,35041.66656,percent of total billed charges,
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA [1000108],AETNA [100010801],,,76.8,,959.77,0.518595,35041.66656,percent of total billed charges,
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA [1000108],AETNA [100010801],,,76.8,,959.77,0.518595,35041.66656,percent of total billed charges,
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA [1000108],AETNA [100010801],,,76.8,,959.77,0.518595,35041.66656,percent of total billed charges,
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA [1000108],AETNA [100010801],,,76.8,,959.77,0.518595,35041.66656,percent of total billed charges,
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA [1000108],AETNA [100010801],,,76.8,,1535.58,0.518595,35041.66656,percent of total billed charges,
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA [1000108],AETNA [100010801],,,76.8,,1535.58,0.518595,35041.66656,percent of total billed charges,
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA [1000108],AETNA [100010801],,,76.8,,1535.58,0.518595,35041.66656,percent of total billed charges,
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA [1000108],AETNA [100010801],,,76.8,,1535.58,0.518595,35041.66656,percent of total billed charges,
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,AETNA [1000108],AETNA [100010801],,,76.8,,1506.8,0.518595,35041.66656,percent of total billed charges,
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,AETNA [1000108],AETNA [100010801],,,76.8,,1645.94,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,AETNA [1000108],AETNA [100010801],,,76.8,,1646.55,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,AETNA [1000108],AETNA [100010801],,,76.8,,1209.27,0.518595,35041.66656,percent of total billed charges,
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,AETNA [1000108],AETNA [100010801],,,76.8,,1573.97,0.518595,35041.66656,percent of total billed charges,
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA [1000108],AETNA [100010801],,,76.8,,1953.58,0.518595,35041.66656,percent of total billed charges,
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA [1000108],AETNA [100010801],,,76.8,,1953.58,0.518595,35041.66656,percent of total billed charges,
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA [1000108],AETNA [100010801],,,76.8,,1953.58,0.518595,35041.66656,percent of total billed charges,
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,AETNA [1000108],AETNA [100010801],,,76.8,,1626.77,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,AETNA [1000108],AETNA [100010801],,,76.8,,1737.12,0.518595,35041.66656,percent of total billed charges,
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,AETNA [1000108],AETNA [100010801],,,76.8,,3004.28,0.518595,35041.66656,percent of total billed charges,
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,AETNA [1000108],AETNA [100010801],,,76.8,,1727.56,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,AETNA [1000108],AETNA [100010801],,,76.8,,307.55,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,AETNA [1000108],AETNA [100010801],,,76.8,,144.84,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,AETNA [1000108],AETNA [100010801],,,76.8,,104.37,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA [1000108],AETNA [100010801],,,76.8,,221.24,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA [1000108],AETNA [100010801],,,76.8,,221.24,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA [1000108],AETNA [100010801],,,76.8,,221.24,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA [1000108],AETNA [100010801],,,76.8,,221.24,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,AETNA [1000108],AETNA [100010801],,,76.8,,459.56,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,AETNA [1000108],AETNA [100010801],,,76.8,,880.55,0.518595,35041.66656,percent of total billed charges,
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,AETNA [1000108],AETNA [100010801],,,76.8,,880.55,0.518595,35041.66656,percent of total billed charges,
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,AETNA [1000108],AETNA [100010801],,,76.8,,6160.25,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA [1000108],AETNA [100010801],,,76.8,,8325.77,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,AETNA [1000108],AETNA [100010801],,,76.8,,6544.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,AETNA [1000108],AETNA [100010801],,,76.8,,6101.91,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA [1000108],AETNA [100010801],,,76.8,,8325.77,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA [1000108],AETNA [100010801],,,76.8,,8325.77,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,AETNA [1000108],AETNA [100010801],,,76.8,,4647.57,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,AETNA [1000108],AETNA [100010801],,,76.8,,5501.2,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,AETNA [1000108],AETNA [100010801],,,76.8,,5074.38,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,AETNA [1000108],AETNA [100010801],,,76.8,,5501.2,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,AETNA [1000108],AETNA [100010801],,,76.8,,5422.16,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,AETNA [1000108],AETNA [100010801],,,76.8,,5754.13,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,AETNA [1000108],AETNA [100010801],,,76.8,,6086.1,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,AETNA [1000108],AETNA [100010801],,,76.8,,6402.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,AETNA [1000108],AETNA [100010801],,,76.8,,6781.66,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,AETNA [1000108],AETNA [100010801],,,76.8,,5358.93,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,AETNA [1000108],AETNA [100010801],,,76.8,,5722.51,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,AETNA [1000108],AETNA [100010801],,,76.8,,6038.68,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,AETNA [1000108],AETNA [100010801],,,76.8,,6734.23,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,AETNA [1000108],AETNA [100010801],,,76.8,,2190.77,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,AETNA [1000108],AETNA [100010801],,,76.8,,2475.28,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,AETNA [1000108],AETNA [100010801],,,76.8,,2742.01,0.518595,35041.66656,percent of total billed charges,
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA [1000108],AETNA [100010801],,,76.8,,354.02,0.518595,35041.66656,percent of total billed charges,
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA [1000108],AETNA [100010801],,,76.8,,354.02,0.518595,35041.66656,percent of total billed charges,
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,AETNA [1000108],AETNA [100010801],,,76.8,,2177.86,0.518595,35041.66656,percent of total billed charges,
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,AETNA [1000108],AETNA [100010801],,,76.8,,3380.45,0.518595,35041.66656,percent of total billed charges,
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,AETNA [1000108],AETNA [100010801],,,76.8,,3380.45,0.518595,35041.66656,percent of total billed charges,
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,AETNA [1000108],AETNA [100010801],,,76.8,,3167.8,0.518595,35041.66656,percent of total billed charges,
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,0.518595,35041.66656,percent of total billed charges,
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,0.518595,35041.66656,percent of total billed charges,
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,0.518595,35041.66656,percent of total billed charges,
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,0.518595,35041.66656,percent of total billed charges,
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,0.518595,35041.66656,percent of total billed charges,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,0.518595,35041.66656,percent of total billed charges,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,0.518595,35041.66656,percent of total billed charges,
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,AETNA [1000108],AETNA [100010801],,,76.8,,157.34,0.518595,35041.66656,percent of total billed charges,
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,AETNA [1000108],AETNA [100010801],,,76.8,,667.53,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,AETNA [1000108],AETNA [100010801],,,76.8,,1348.25,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,AETNA [1000108],AETNA [100010801],,,76.8,,4852.91,0.518595,35041.66656,percent of total billed charges,
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,AETNA [1000108],AETNA [100010801],,,76.8,,8080.25,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,AETNA [1000108],AETNA [100010801],,,76.8,,11595.39,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,AETNA [1000108],AETNA [100010801],,,76.8,,4271.82,0.518595,35041.66656,percent of total billed charges,
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,AETNA [1000108],AETNA [100010801],,,76.8,,5058.38,0.518595,35041.66656,percent of total billed charges,
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,AETNA [1000108],AETNA [100010801],,,76.8,,4873.21,0.518595,35041.66656,percent of total billed charges,
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,AETNA [1000108],AETNA [100010801],,,76.8,,8338.6,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,AETNA [1000108],AETNA [100010801],,,76.8,,752.86,0.518595,35041.66656,percent of total billed charges,
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA [1000108],AETNA [100010801],,,76.8,,5162.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA [1000108],AETNA [100010801],,,76.8,,5162.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA [1000108],AETNA [100010801],,,76.8,,5162.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA [1000108],AETNA [100010801],,,76.8,,5162.88,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA [1000108],AETNA [100010801],,,76.8,,5593.11,0.518595,35041.66656,percent of total billed charges,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,AETNA [1000108],AETNA [100010801],,,76.8,,2507.84,0.518595,35041.66656,percent of total billed charges,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,AETNA [1000108],AETNA [100010801],,,76.8,,2507.84,0.518595,35041.66656,percent of total billed charges,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA [1000108],AETNA [100010801],,,76.8,,5593.11,0.518595,35041.66656,percent of total billed charges,
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,AETNA [1000108],AETNA [100010801],,,76.8,,103.07,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,AETNA [1000108],AETNA [100010801],,,76.8,,213.98,0.518595,35041.66656,percent of total billed charges,
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,AETNA [1000108],AETNA [100010801],,,76.8,,152.36,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,0.518595,35041.66656,percent of total billed charges,
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,AETNA [1000108],AETNA [100010801],,,76.8,,3292.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,AETNA [1000108],AETNA [100010801],,,76.8,,5221.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,AETNA [1000108],AETNA [100010801],,,76.8,,1172.38,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,AETNA [1000108],AETNA [100010801],,,76.8,,928.14,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,AETNA [1000108],AETNA [100010801],,,76.8,,928.14,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,AETNA [1000108],AETNA [100010801],,,76.8,,1025.84,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,AETNA [1000108],AETNA [100010801],,,76.8,,1025.84,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,AETNA [1000108],AETNA [100010801],,,76.8,,4321.95,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,AETNA [1000108],AETNA [100010801],,,76.8,,4361.06,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,AETNA [1000108],AETNA [100010801],,,76.8,,4321.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,0.518595,35041.66656,percent of total billed charges,
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,AETNA [1000108],AETNA [100010801],,,76.8,,885.59,0.518595,35041.66656,percent of total billed charges,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,AETNA [1000108],AETNA [100010801],,,76.8,,10741.92,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,AETNA [1000108],AETNA [100010801],,,76.8,,3340.12,0.518595,35041.66656,percent of total billed charges,
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,AETNA [1000108],AETNA [100010801],,,76.8,,4078.32,0.518595,35041.66656,percent of total billed charges,
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,AETNA [1000108],AETNA [100010801],,,76.8,,6541.6,0.518595,35041.66656,percent of total billed charges,
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,AETNA [1000108],AETNA [100010801],,,76.8,,11034.43,0.518595,35041.66656,percent of total billed charges,
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,AETNA [1000108],AETNA [100010801],,,76.8,,15832.1,0.518595,35041.66656,percent of total billed charges,
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,AETNA [1000108],AETNA [100010801],,,76.8,,1473.62,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA [1000108],AETNA [100010801],,,76.8,,775.27,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,AETNA [1000108],AETNA [100010801],,,76.8,,4097.06,0.518595,35041.66656,percent of total billed charges,
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA [1000108],AETNA [100010801],,,76.8,,7125.03,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,AETNA [1000108],AETNA [100010801],,,76.8,,887.43,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA [1000108],AETNA [100010801],,,76.8,,7125.03,0.518595,35041.66656,percent of total billed charges,
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,AETNA [1000108],AETNA [100010801],,,76.8,,6531.82,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA [1000108],AETNA [100010801],,,76.8,,882.82,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA [1000108],AETNA [100010801],,,76.8,,7125.03,0.518595,35041.66656,percent of total billed charges,
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,AETNA [1000108],AETNA [100010801],,,76.8,,21038.98,0.518595,35041.66656,percent of total billed charges,
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,0.518595,35041.66656,percent of total billed charges,
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,AETNA [1000108],AETNA [100010801],,,76.8,,3270.46,0.518595,35041.66656,percent of total billed charges,
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,0.518595,35041.66656,percent of total billed charges,
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,AETNA [1000108],AETNA [100010801],,,76.8,,3336.45,0.518595,35041.66656,percent of total billed charges,
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,AETNA [1000108],AETNA [100010801],,,76.8,,317.81,0.518595,35041.66656,percent of total billed charges,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,AETNA [1000108],AETNA [100010801],,,76.8,,317.81,0.518595,35041.66656,percent of total billed charges,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,AETNA [1000108],AETNA [100010801],,,76.8,,63.56,0.518595,35041.66656,percent of total billed charges,
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,AETNA [1000108],AETNA [100010801],,,76.8,,2082.53,0.518595,35041.66656,percent of total billed charges,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,0.518595,35041.66656,percent of total billed charges,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,0.518595,35041.66656,percent of total billed charges,
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,0.518595,35041.66656,percent of total billed charges,
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,0.518595,35041.66656,percent of total billed charges,
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,AETNA [1000108],AETNA [100010801],,,76.8,,1659.25,0.518595,35041.66656,percent of total billed charges,
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,AETNA [1000108],AETNA [100010801],,,76.8,,801.03,0.518595,35041.66656,percent of total billed charges,
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,AETNA [1000108],AETNA [100010801],,,76.8,,1007.52,0.518595,35041.66656,percent of total billed charges,
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,AETNA [1000108],AETNA [100010801],,,76.8,,851,0.518595,35041.66656,percent of total billed charges,
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,AETNA [1000108],AETNA [100010801],,,76.8,,901.27,0.518595,35041.66656,percent of total billed charges,
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,AETNA [1000108],AETNA [100010801],,,76.8,,1234.26,0.518595,35041.66656,percent of total billed charges,
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,AETNA [1000108],AETNA [100010801],,,76.8,,1519.22,0.518595,35041.66656,percent of total billed charges,
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,AETNA [1000108],AETNA [100010801],,,76.8,,1816.79,0.518595,35041.66656,percent of total billed charges,
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,AETNA [1000108],AETNA [100010801],,,76.8,,2021.96,0.518595,35041.66656,percent of total billed charges,
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,AETNA [1000108],AETNA [100010801],,,76.8,,6583.16,0.518595,35041.66656,percent of total billed charges,
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,AETNA [1000108],AETNA [100010801],,,76.8,,1617.73,0.518595,35041.66656,percent of total billed charges,
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,AETNA [1000108],AETNA [100010801],,,76.8,,1185.01,0.518595,35041.66656,percent of total billed charges,
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,AETNA [1000108],AETNA [100010801],,,76.8,,1975.1,0.518595,35041.66656,percent of total billed charges,
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,AETNA [1000108],AETNA [100010801],,,76.8,,1606.74,0.518595,35041.66656,percent of total billed charges,
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,AETNA [1000108],AETNA [100010801],,,76.8,,2073.73,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,AETNA [1000108],AETNA [100010801],,,76.8,,1422.74,0.518595,35041.66656,percent of total billed charges,
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,AETNA [1000108],AETNA [100010801],,,76.8,,1422.74,0.518595,35041.66656,percent of total billed charges,
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,AETNA [1000108],AETNA [100010801],,,76.8,,2021.55,0.518595,35041.66656,percent of total billed charges,
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,AETNA [1000108],AETNA [100010801],,,76.8,,2021.55,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,AETNA [1000108],AETNA [100010801],,,76.8,,1593.31,0.518595,35041.66656,percent of total billed charges,
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,AETNA [1000108],AETNA [100010801],,,76.8,,1655.99,0.518595,35041.66656,percent of total billed charges,
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,AETNA [1000108],AETNA [100010801],,,76.8,,2035.6,0.518595,35041.66656,percent of total billed charges,
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,AETNA [1000108],AETNA [100010801],,,76.8,,1952.35,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,AETNA [1000108],AETNA [100010801],,,76.8,,2445.88,0.518595,35041.66656,percent of total billed charges,
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,AETNA [1000108],AETNA [100010801],,,76.8,,2885.48,0.518595,35041.66656,percent of total billed charges,
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,AETNA [1000108],AETNA [100010801],,,76.8,,2114.07,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,AETNA [1000108],AETNA [100010801],,,76.8,,3073.21,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,AETNA [1000108],AETNA [100010801],,,76.8,,3073.21,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,AETNA [1000108],AETNA [100010801],,,76.8,,3134.07,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,AETNA [1000108],AETNA [100010801],,,76.8,,3290.63,0.518595,35041.66656,percent of total billed charges,
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,AETNA [1000108],AETNA [100010801],,,76.8,,3189.07,0.518595,35041.66656,percent of total billed charges,
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,AETNA [1000108],AETNA [100010801],,,76.8,,2623.33,0.518595,35041.66656,percent of total billed charges,
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,AETNA [1000108],AETNA [100010801],,,76.8,,3364.67,0.518595,35041.66656,percent of total billed charges,
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,AETNA [1000108],AETNA [100010801],,,76.8,,3433.77,0.518595,35041.66656,percent of total billed charges,
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,AETNA [1000108],AETNA [100010801],,,76.8,,2971.28,0.518595,35041.66656,percent of total billed charges,
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,AETNA [1000108],AETNA [100010801],,,76.8,,4388.28,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,AETNA [1000108],AETNA [100010801],,,76.8,,1894.13,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,AETNA [1000108],AETNA [100010801],,,76.8,,1864.75,0.518595,35041.66656,percent of total billed charges,
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,AETNA [1000108],AETNA [100010801],,,76.8,,1847.15,0.518595,35041.66656,percent of total billed charges,
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,AETNA [1000108],AETNA [100010801],,,76.8,,5523.04,0.518595,35041.66656,percent of total billed charges,
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,AETNA [1000108],AETNA [100010801],,,76.8,,2380.98,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,AETNA [1000108],AETNA [100010801],,,76.8,,2380.98,0.518595,35041.66656,percent of total billed charges,
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,AETNA [1000108],AETNA [100010801],,,76.8,,2457.24,0.518595,35041.66656,percent of total billed charges,
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,AETNA [1000108],AETNA [100010801],,,76.8,,2765.96,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,AETNA [1000108],AETNA [100010801],,,76.8,,3003.54,0.518595,35041.66656,percent of total billed charges,
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,AETNA [1000108],AETNA [100010801],,,76.8,,3541.04,0.518595,35041.66656,percent of total billed charges,
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,AETNA [1000108],AETNA [100010801],,,76.8,,3051.94,0.518595,35041.66656,percent of total billed charges,
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,AETNA [1000108],AETNA [100010801],,,76.8,,3309.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,AETNA [1000108],AETNA [100010801],,,76.8,,3297.85,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,AETNA [1000108],AETNA [100010801],,,76.8,,3817.73,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,AETNA [1000108],AETNA [100010801],,,76.8,,3816.74,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA [1000108],AETNA [100010801],,,76.8,,3858.47,0.518595,35041.66656,percent of total billed charges,
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA [1000108],AETNA [100010801],,,76.8,,3858.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,AETNA [1000108],AETNA [100010801],,,76.8,,4079.13,0.518595,35041.66656,percent of total billed charges,
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,AETNA [1000108],AETNA [100010801],,,76.8,,3532.98,0.518595,35041.66656,percent of total billed charges,
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA [1000108],AETNA [100010801],,,76.8,,3858.47,0.518595,35041.66656,percent of total billed charges,
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,AETNA [1000108],AETNA [100010801],,,76.8,,3486.24,0.518595,35041.66656,percent of total billed charges,
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,AETNA [1000108],AETNA [100010801],,,76.8,,3638.94,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,AETNA [1000108],AETNA [100010801],,,76.8,,4176.58,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,AETNA [1000108],AETNA [100010801],,,76.8,,4361.72,0.518595,35041.66656,percent of total billed charges,
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,AETNA [1000108],AETNA [100010801],,,76.8,,5707.85,0.518595,35041.66656,percent of total billed charges,
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,AETNA [1000108],AETNA [100010801],,,76.8,,5389.73,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,AETNA [1000108],AETNA [100010801],,,76.8,,5935.03,0.518595,35041.66656,percent of total billed charges,
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,AETNA [1000108],AETNA [100010801],,,76.8,,4207.87,0.518595,35041.66656,percent of total billed charges,
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA [1000108],AETNA [100010801],,,76.8,,4462.76,0.518595,35041.66656,percent of total billed charges,
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,AETNA [1000108],AETNA [100010801],,,76.8,,5857.45,0.518595,35041.66656,percent of total billed charges,
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA [1000108],AETNA [100010801],,,76.8,,5027.61,0.518595,35041.66656,percent of total billed charges,
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,AETNA [1000108],AETNA [100010801],,,76.8,,6598.64,0.518595,35041.66656,percent of total billed charges,
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,AETNA [1000108],AETNA [100010801],,,76.8,,5302.7,0.518595,35041.66656,percent of total billed charges,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,AETNA [1000108],AETNA [100010801],,,76.8,,5857.45,0.518595,35041.66656,percent of total billed charges,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA [1000108],AETNA [100010801],,,76.8,,4462.76,0.518595,35041.66656,percent of total billed charges,
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,AETNA [1000108],AETNA [100010801],,,76.8,,6150.47,0.518595,35041.66656,percent of total billed charges,
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA [1000108],AETNA [100010801],,,76.8,,5027.61,0.518595,35041.66656,percent of total billed charges,
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,AETNA [1000108],AETNA [100010801],,,76.8,,6598.64,0.518595,35041.66656,percent of total billed charges,
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA [1000108],AETNA [100010801],,,76.8,,5027.61,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA [1000108],AETNA [100010801],,,76.8,,5027.61,0.518595,35041.66656,percent of total billed charges,
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,AETNA [1000108],AETNA [100010801],,,76.8,,4788.05,0.518595,35041.66656,percent of total billed charges,
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,AETNA [1000108],AETNA [100010801],,,76.8,,6225.76,0.518595,35041.66656,percent of total billed charges,
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,AETNA [1000108],AETNA [100010801],,,76.8,,5302.7,0.518595,35041.66656,percent of total billed charges,
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,AETNA [1000108],AETNA [100010801],,,76.8,,5420.04,0.518595,35041.66656,percent of total billed charges,
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,AETNA [1000108],AETNA [100010801],,,76.8,,5420.04,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,AETNA [1000108],AETNA [100010801],,,76.8,,10158.77,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,AETNA [1000108],AETNA [100010801],,,76.8,,4466.67,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,AETNA [1000108],AETNA [100010801],,,76.8,,4466.67,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,AETNA [1000108],AETNA [100010801],,,76.8,,3359.19,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,AETNA [1000108],AETNA [100010801],,,76.8,,4844.11,0.518595,35041.66656,percent of total billed charges,
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,AETNA [1000108],AETNA [100010801],,,76.8,,261.26,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,AETNA [1000108],AETNA [100010801],,,76.8,,3320.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,AETNA [1000108],AETNA [100010801],,,76.8,,3499.94,0.518595,35041.66656,percent of total billed charges,
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,AETNA [1000108],AETNA [100010801],,,76.8,,7411.53,0.518595,35041.66656,percent of total billed charges,
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,AETNA [1000108],AETNA [100010801],,,76.8,,7411.53,0.518595,35041.66656,percent of total billed charges,
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA [1000108],AETNA [100010801],,,76.8,,9012.15,0.518595,35041.66656,percent of total billed charges,
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,AETNA [1000108],AETNA [100010801],,,76.8,,7136.76,0.518595,35041.66656,percent of total billed charges,
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,AETNA [1000108],AETNA [100010801],,,76.8,,8570.72,0.518595,35041.66656,percent of total billed charges,
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA [1000108],AETNA [100010801],,,76.8,,9012.15,0.518595,35041.66656,percent of total billed charges,
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA [1000108],AETNA [100010801],,,76.8,,9012.15,0.518595,35041.66656,percent of total billed charges,
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,AETNA [1000108],AETNA [100010801],,,76.8,,8802.84,0.518595,35041.66656,percent of total billed charges,
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,AETNA [1000108],AETNA [100010801],,,76.8,,4126.72,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,AETNA [1000108],AETNA [100010801],,,76.8,,4267.19,0.518595,35041.66656,percent of total billed charges,
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,AETNA [1000108],AETNA [100010801],,,76.8,,4268.5,0.518595,35041.66656,percent of total billed charges,
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,AETNA [1000108],AETNA [100010801],,,76.8,,4075.22,0.518595,35041.66656,percent of total billed charges,
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,AETNA [1000108],AETNA [100010801],,,76.8,,4357.81,0.518595,35041.66656,percent of total billed charges,
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,AETNA [1000108],AETNA [100010801],,,76.8,,4282.84,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA [1000108],AETNA [100010801],,,76.8,,8037.66,0.518595,35041.66656,percent of total billed charges,
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,AETNA [1000108],AETNA [100010801],,,76.8,,7443.8,0.518595,35041.66656,percent of total billed charges,
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,AETNA [1000108],AETNA [100010801],,,76.8,,7136.11,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,AETNA [1000108],AETNA [100010801],,,76.8,,7244.45,0.518595,35041.66656,percent of total billed charges,
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,AETNA [1000108],AETNA [100010801],,,76.8,,7443.8,0.518595,35041.66656,percent of total billed charges,
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,AETNA [1000108],AETNA [100010801],,,76.8,,7136.11,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,AETNA [1000108],AETNA [100010801],,,76.8,,3320.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,AETNA [1000108],AETNA [100010801],,,76.8,,4357.81,0.518595,35041.66656,percent of total billed charges,
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,AETNA [1000108],AETNA [100010801],,,76.8,,190.46,0.518595,35041.66656,percent of total billed charges,
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,AETNA [1000108],AETNA [100010801],,,76.8,,228.55,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,AETNA [1000108],AETNA [100010801],,,76.8,,826.8,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,AETNA [1000108],AETNA [100010801],,,76.8,,826.8,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA [1000108],AETNA [100010801],,,76.8,,814.69,0.518595,35041.66656,percent of total billed charges,
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,AETNA [1000108],AETNA [100010801],,,76.8,,678.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA [1000108],AETNA [100010801],,,76.8,,502.8,0.518595,35041.66656,percent of total billed charges,
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,AETNA [1000108],AETNA [100010801],,,76.8,,226.58,0.518595,35041.66656,percent of total billed charges,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,AETNA [1000108],AETNA [100010801],,,76.8,,726.41,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,AETNA [1000108],AETNA [100010801],,,76.8,,479.05,0.518595,35041.66656,percent of total billed charges,
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA [1000108],AETNA [100010801],,,76.8,,814.69,0.518595,35041.66656,percent of total billed charges,
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA [1000108],AETNA [100010801],,,76.8,,889.54,0.518595,35041.66656,percent of total billed charges,
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA [1000108],AETNA [100010801],,,76.8,,889.54,0.518595,35041.66656,percent of total billed charges,
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA [1000108],AETNA [100010801],,,76.8,,889.54,0.518595,35041.66656,percent of total billed charges,
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA [1000108],AETNA [100010801],,,76.8,,1875.82,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA [1000108],AETNA [100010801],,,76.8,,1875.82,0.518595,35041.66656,percent of total billed charges,
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA [1000108],AETNA [100010801],,,76.8,,1875.82,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA [1000108],AETNA [100010801],,,76.8,,1875.82,0.518595,35041.66656,percent of total billed charges,
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA [1000108],AETNA [100010801],,,76.8,,502.8,0.518595,35041.66656,percent of total billed charges,
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA [1000108],AETNA [100010801],,,76.8,,502.8,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA [1000108],AETNA [100010801],,,76.8,,814.69,0.518595,35041.66656,percent of total billed charges,
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,AETNA [1000108],AETNA [100010801],,,76.8,,1786.67,0.518595,35041.66656,percent of total billed charges,
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,AETNA [1000108],AETNA [100010801],,,76.8,,1787.04,0.518595,35041.66656,percent of total billed charges,
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,AETNA [1000108],AETNA [100010801],,,76.8,,1786.67,0.518595,35041.66656,percent of total billed charges,
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,AETNA [1000108],AETNA [100010801],,,76.8,,1311.2,0.518595,35041.66656,percent of total billed charges,
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,AETNA [1000108],AETNA [100010801],,,76.8,,2765.96,0.518595,35041.66656,percent of total billed charges,
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,0.518595,35041.66656,percent of total billed charges,
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA [1000108],AETNA [100010801],,,76.8,,125.48,0.518595,35041.66656,percent of total billed charges,
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,AETNA [1000108],AETNA [100010801],,,76.8,,3593.1,0.518595,35041.66656,percent of total billed charges,
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,AETNA [1000108],AETNA [100010801],,,76.8,,1740.35,0.518595,35041.66656,percent of total billed charges,
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,AETNA [1000108],AETNA [100010801],,,76.8,,1851.55,0.518595,35041.66656,percent of total billed charges,
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,AETNA [1000108],AETNA [100010801],,,76.8,,1851.55,0.518595,35041.66656,percent of total billed charges,
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,AETNA [1000108],AETNA [100010801],,,76.8,,4168.77,0.518595,35041.66656,percent of total billed charges,
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,AETNA [1000108],AETNA [100010801],,,76.8,,4742.42,0.518595,35041.66656,percent of total billed charges,
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,AETNA [1000108],AETNA [100010801],,,76.8,,4742.42,0.518595,35041.66656,percent of total billed charges,
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,AETNA [1000108],AETNA [100010801],,,76.8,,5016.21,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,76.8,,94.11,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,AETNA [1000108],AETNA [100010801],,,76.8,,3699.41,0.518595,35041.66656,percent of total billed charges,
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,AETNA [1000108],AETNA [100010801],,,76.8,,3438.66,0.518595,35041.66656,percent of total billed charges,
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA [1000108],AETNA [100010801],,,76.8,,3308.28,0.518595,35041.66656,percent of total billed charges,
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA [1000108],AETNA [100010801],,,76.8,,3308.28,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,76.8,,304.73,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,76.8,,380.91,0.518595,35041.66656,percent of total billed charges,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,AETNA [1000108],AETNA [100010801],,,76.8,,165.81,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA [1000108],AETNA [100010801],,,76.8,,1176.45,0.518595,35041.66656,percent of total billed charges,
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA [1000108],AETNA [100010801],,,76.8,,1176.45,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA [1000108],AETNA [100010801],,,76.8,,902.12,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,0.518595,35041.66656,percent of total billed charges,
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA [1000108],AETNA [100010801],,,76.8,,902.12,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA [1000108],AETNA [100010801],,,76.8,,902.12,0.518595,35041.66656,percent of total billed charges,
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,AETNA [1000108],AETNA [100010801],,,76.8,,201.66,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,AETNA [1000108],AETNA [100010801],,,76.8,,201.66,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,AETNA [1000108],AETNA [100010801],,,76.8,,4546.85,0.518595,35041.66656,percent of total billed charges,
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,AETNA [1000108],AETNA [100010801],,,76.8,,1648.67,0.518595,35041.66656,percent of total billed charges,
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,0.518595,35041.66656,percent of total billed charges,
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,AETNA [1000108],AETNA [100010801],,,76.8,,869.37,0.518595,35041.66656,percent of total billed charges,
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,AETNA [1000108],AETNA [100010801],,,76.8,,1811.5,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,AETNA [1000108],AETNA [100010801],,,76.8,,1892.91,0.518595,35041.66656,percent of total billed charges,
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,76.8,,1506.19,0.518595,35041.66656,percent of total billed charges,
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,76.8,,1506.19,0.518595,35041.66656,percent of total billed charges,
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA [1000108],AETNA [100010801],,,76.8,,911.85,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA [1000108],AETNA [100010801],,,76.8,,911.85,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA [1000108],AETNA [100010801],,,76.8,,911.85,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA [1000108],AETNA [100010801],,,76.8,,911.85,0.518595,35041.66656,percent of total billed charges,
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,AETNA [1000108],AETNA [100010801],,,76.8,,869.37,0.518595,35041.66656,percent of total billed charges,
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,AETNA [1000108],AETNA [100010801],,,76.8,,1363.71,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,AETNA [1000108],AETNA [100010801],,,76.8,,1770.79,0.518595,35041.66656,percent of total billed charges,
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,AETNA [1000108],AETNA [100010801],,,76.8,,1058.4,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,76.8,,1587.61,0.518595,35041.66656,percent of total billed charges,
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,76.8,,1384.07,0.518595,35041.66656,percent of total billed charges,
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,AETNA [1000108],AETNA [100010801],,,76.8,,1363.71,0.518595,35041.66656,percent of total billed charges,
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA [1000108],AETNA [100010801],,,76.8,,1445.13,0.518595,35041.66656,percent of total billed charges,
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA [1000108],AETNA [100010801],,,76.8,,1241.59,0.518595,35041.66656,percent of total billed charges,
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA [1000108],AETNA [100010801],,,76.8,,1241.59,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,0.518595,35041.66656,percent of total billed charges,
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,76.8,,1384.07,0.518595,35041.66656,percent of total billed charges,
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,0.518595,35041.66656,percent of total billed charges,
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,0.518595,35041.66656,percent of total billed charges,
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,0.518595,35041.66656,percent of total billed charges,
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,76.8,,1526.55,0.518595,35041.66656,percent of total billed charges,
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,76.8,,1913.27,0.518595,35041.66656,percent of total billed charges,
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,0.518595,35041.66656,percent of total billed charges,
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA [1000108],AETNA [100010801],,,76.8,,1872.56,0.518595,35041.66656,percent of total billed charges,
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA [1000108],AETNA [100010801],,,76.8,,1943.21,0.518595,35041.66656,percent of total billed charges,
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,AETNA [1000108],AETNA [100010801],,,76.8,,6225.44,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,0.518595,35041.66656,percent of total billed charges,
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA [1000108],AETNA [100010801],,,76.8,,1445.13,0.518595,35041.66656,percent of total billed charges,
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,76.8,,1506.19,0.518595,35041.66656,percent of total billed charges,
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,0.518595,35041.66656,percent of total billed charges,
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,0.518595,35041.66656,percent of total billed charges,
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,0.518595,35041.66656,percent of total billed charges,
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,0.518595,35041.66656,percent of total billed charges,
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,0.518595,35041.66656,percent of total billed charges,
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,76.8,,1913.27,0.518595,35041.66656,percent of total billed charges,
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,76.8,,1913.27,0.518595,35041.66656,percent of total billed charges,
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,76.8,,1913.27,0.518595,35041.66656,percent of total billed charges,
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA [1000108],AETNA [100010801],,,76.8,,1943.21,0.518595,35041.66656,percent of total billed charges,
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA [1000108],AETNA [100010801],,,76.8,,1943.21,0.518595,35041.66656,percent of total billed charges,
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,0.518595,35041.66656,percent of total billed charges,
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA [1000108],AETNA [100010801],,,76.8,,542.24,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,0.518595,35041.66656,percent of total billed charges,
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,AETNA [1000108],AETNA [100010801],,,76.8,,183.74,0.518595,35041.66656,percent of total billed charges,
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,AETNA [1000108],AETNA [100010801],,,76.8,,2280.52,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,AETNA [1000108],AETNA [100010801],,,76.8,,6176.55,0.518595,35041.66656,percent of total billed charges,
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,AETNA [1000108],AETNA [100010801],,,76.8,,6176.55,0.518595,35041.66656,percent of total billed charges,
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,0.518595,35041.66656,percent of total billed charges,
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,0.518595,35041.66656,percent of total billed charges,
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,0.518595,35041.66656,percent of total billed charges,
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,0.518595,35041.66656,percent of total billed charges,
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,0.518595,35041.66656,percent of total billed charges,
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,76.8,,380.91,0.518595,35041.66656,percent of total billed charges,
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,76.8,,67.22,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,0.518595,35041.66656,percent of total billed charges,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,AETNA [1000108],AETNA [100010801],,,76.8,,3829.79,0.518595,35041.66656,percent of total billed charges,
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,0.518595,35041.66656,percent of total billed charges,
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,AETNA [1000108],AETNA [100010801],,,76.8,,4846.72,0.518595,35041.66656,percent of total billed charges,
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,0.518595,35041.66656,percent of total billed charges,
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,76.8,,2658.16,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA [1000108],AETNA [100010801],,,76.8,,1078.76,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,AETNA [1000108],AETNA [100010801],,,76.8,,1139.82,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,AETNA [1000108],AETNA [100010801],,,76.8,,3340.88,0.518595,35041.66656,percent of total billed charges,
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,0.518595,35041.66656,percent of total billed charges,
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA [1000108],AETNA [100010801],,,76.8,,4155.72,0.518595,35041.66656,percent of total billed charges,
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,AETNA [1000108],AETNA [100010801],,,76.8,,9695.39,0.518595,35041.66656,percent of total billed charges,
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,0.518595,35041.66656,percent of total billed charges,
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,76.8,,358.5,0.518595,35041.66656,percent of total billed charges,
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,76.8,,1119.47,0.518595,35041.66656,percent of total billed charges,
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,AETNA [1000108],AETNA [100010801],,,76.8,,4522.9,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,AETNA [1000108],AETNA [100010801],,,76.8,,1892.91,0.518595,35041.66656,percent of total billed charges,
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,AETNA [1000108],AETNA [100010801],,,76.8,,2210.86,0.518595,35041.66656,percent of total billed charges,
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,0.518595,35041.66656,percent of total billed charges,
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA [1000108],AETNA [100010801],,,76.8,,8255.34,0.518595,35041.66656,percent of total billed charges,
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,0.518595,35041.66656,percent of total billed charges,
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,0.518595,35041.66656,percent of total billed charges,
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,0.518595,35041.66656,percent of total billed charges,
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,76.8,,1510.26,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,76.8,,1510.26,0.518595,35041.66656,percent of total billed charges,
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,AETNA [1000108],AETNA [100010801],,,76.8,,372.84,0.518595,35041.66656,percent of total billed charges,
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA [1000108],AETNA [100010801],,,76.8,,30123.13,0.518595,35041.66656,percent of total billed charges,
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,AETNA [1000108],AETNA [100010801],,,76.8,,28417.94,0.518595,35041.66656,percent of total billed charges,
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,AETNA [1000108],AETNA [100010801],,,76.8,,582.61,0.518595,35041.66656,percent of total billed charges,
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,AETNA [1000108],AETNA [100010801],,,76.8,,705.8,0.518595,35041.66656,percent of total billed charges,
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,AETNA [1000108],AETNA [100010801],,,76.8,,846.72,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,AETNA [1000108],AETNA [100010801],,,76.8,,416.76,0.518595,35041.66656,percent of total billed charges,
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,AETNA [1000108],AETNA [100010801],,,76.8,,1523.9,0.518595,35041.66656,percent of total billed charges,
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,AETNA [1000108],AETNA [100010801],,,76.8,,16254.03,0.518595,35041.66656,percent of total billed charges,
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,0.518595,35041.66656,percent of total billed charges,
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,0.518595,35041.66656,percent of total billed charges,
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,0.518595,35041.66656,percent of total billed charges,
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,AETNA [1000108],AETNA [100010801],,,76.8,,1813.53,0.518595,35041.66656,percent of total billed charges,
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,AETNA [1000108],AETNA [100010801],,,76.8,,24208.02,0.518595,35041.66656,percent of total billed charges,
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA [1000108],AETNA [100010801],,,76.8,,4481.66,0.518595,35041.66656,percent of total billed charges,
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA [1000108],AETNA [100010801],,,76.8,,4481.66,0.518595,35041.66656,percent of total billed charges,
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,76.8,,1587.61,0.518595,35041.66656,percent of total billed charges,
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,76.8,,1587.61,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,AETNA [1000108],AETNA [100010801],,,76.8,,2655.01,0.518595,35041.66656,percent of total billed charges,
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,AETNA [1000108],AETNA [100010801],,,76.8,,1227.34,0.518595,35041.66656,percent of total billed charges,
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,AETNA [1000108],AETNA [100010801],,,76.8,,743.89,0.518595,35041.66656,percent of total billed charges,
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,AETNA [1000108],AETNA [100010801],,,76.8,,10194.42,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA [1000108],AETNA [100010801],,,76.8,,7125.03,0.518595,35041.66656,percent of total billed charges,
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,AETNA [1000108],AETNA [100010801],,,76.8,,112.04,0.518595,35041.66656,percent of total billed charges,
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,AETNA [1000108],AETNA [100010801],,,76.8,,112.04,0.518595,35041.66656,percent of total billed charges,
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,AETNA [1000108],AETNA [100010801],,,76.8,,7627.99,0.518595,35041.66656,percent of total billed charges,
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,AETNA [1000108],AETNA [100010801],,,76.8,,14925.19,0.518595,35041.66656,percent of total billed charges,
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA [1000108],AETNA [100010801],,,76.8,,613.94,0.518595,35041.66656,percent of total billed charges,
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA [1000108],AETNA [100010801],,,76.8,,613.94,0.518595,35041.66656,percent of total billed charges,
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA [1000108],AETNA [100010801],,,76.8,,613.94,0.518595,35041.66656,percent of total billed charges,
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,AETNA [1000108],AETNA [100010801],,,76.8,,488.46,0.518595,35041.66656,percent of total billed charges,
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,AETNA [1000108],AETNA [100010801],,,76.8,,2940.11,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,76.8,,2658.16,0.518595,35041.66656,percent of total billed charges,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,AETNA [1000108],AETNA [100010801],,,76.8,,879.29,0.518595,35041.66656,percent of total billed charges,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,AETNA [1000108],AETNA [100010801],,,76.8,,879.29,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,AETNA [1000108],AETNA [100010801],,,76.8,,895.57,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,AETNA [1000108],AETNA [100010801],,,76.8,,993.27,0.518595,35041.66656,percent of total billed charges,
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,AETNA [1000108],AETNA [100010801],,,76.8,,13864.4,0.518595,35041.66656,percent of total billed charges,
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA [1000108],AETNA [100010801],,,76.8,,17337.63,0.518595,35041.66656,percent of total billed charges,
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA [1000108],AETNA [100010801],,,76.8,,17337.63,0.518595,35041.66656,percent of total billed charges,
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,AETNA [1000108],AETNA [100010801],,,76.8,,5355.18,0.518595,35041.66656,percent of total billed charges,
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,AETNA [1000108],AETNA [100010801],,,76.8,,7486.26,0.518595,35041.66656,percent of total billed charges,
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,AETNA [1000108],AETNA [100010801],,,76.8,,6776.28,0.518595,35041.66656,percent of total billed charges,
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,AETNA [1000108],AETNA [100010801],,,76.8,,6776.28,0.518595,35041.66656,percent of total billed charges,
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,AETNA [1000108],AETNA [100010801],,,76.8,,7486.26,0.518595,35041.66656,percent of total billed charges,
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,AETNA [1000108],AETNA [100010801],,,76.8,,5001.54,0.518595,35041.66656,percent of total billed charges,
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,0.518595,35041.66656,percent of total billed charges,
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,0.518595,35041.66656,percent of total billed charges,
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,AETNA [1000108],AETNA [100010801],,,76.8,,3366.19,0.518595,35041.66656,percent of total billed charges,
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,AETNA [1000108],AETNA [100010801],,,76.8,,534.45,0.518595,35041.66656,percent of total billed charges,
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,AETNA [1000108],AETNA [100010801],,,76.8,,662.33,0.518595,35041.66656,percent of total billed charges,
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,AETNA [1000108],AETNA [100010801],,,76.8,,795.31,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA [1000108],AETNA [100010801],,,76.8,,775.27,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA [1000108],AETNA [100010801],,,76.8,,775.27,0.518595,35041.66656,percent of total billed charges,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,AETNA [1000108],AETNA [100010801],,,76.8,,3716.42,0.518595,35041.66656,percent of total billed charges,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,AETNA [1000108],AETNA [100010801],,,76.8,,3716.42,0.518595,35041.66656,percent of total billed charges,
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,AETNA [1000108],AETNA [100010801],,,76.8,,2025.09,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA [1000108],AETNA [100010801],,,76.8,,882.82,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA [1000108],AETNA [100010801],,,76.8,,882.82,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA [1000108],AETNA [100010801],,,76.8,,882.82,0.518595,35041.66656,percent of total billed charges,
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,AETNA [1000108],AETNA [100010801],,,76.8,,7228.02,0.518595,35041.66656,percent of total billed charges,
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,AETNA [1000108],AETNA [100010801],,,76.8,,11271.43,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,AETNA [1000108],AETNA [100010801],,,76.8,,5442.89,0.518595,35041.66656,percent of total billed charges,
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,AETNA [1000108],AETNA [100010801],,,76.8,,703.56,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,0.518595,35041.66656,percent of total billed charges,
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,0.518595,35041.66656,percent of total billed charges,
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,AETNA [1000108],AETNA [100010801],,,76.8,,325.97,0.518595,35041.66656,percent of total billed charges,
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,AETNA [1000108],AETNA [100010801],,,76.8,,4775.01,0.518595,35041.66656,percent of total billed charges,
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,AETNA [1000108],AETNA [100010801],,,76.8,,4928.2,0.518595,35041.66656,percent of total billed charges,
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,AETNA [1000108],AETNA [100010801],,,76.8,,1990.87,0.518595,35041.66656,percent of total billed charges,
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,AETNA [1000108],AETNA [100010801],,,76.8,,434.69,0.518595,35041.66656,percent of total billed charges,
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,AETNA [1000108],AETNA [100010801],,,76.8,,7656.31,0.518595,35041.66656,percent of total billed charges,
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,0.518595,35041.66656,percent of total billed charges,
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,0.518595,35041.66656,percent of total billed charges,
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,AETNA [1000108],AETNA [100010801],,,76.8,,7656.31,0.518595,35041.66656,percent of total billed charges,
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,0.518595,35041.66656,percent of total billed charges,
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,AETNA [1000108],AETNA [100010801],,,76.8,,3549.48,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,AETNA [1000108],AETNA [100010801],,,76.8,,439.17,0.518595,35041.66656,percent of total billed charges,
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,76.8,,235.27,0.518595,35041.66656,percent of total billed charges,
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,AETNA [1000108],AETNA [100010801],,,76.8,,7151.77,0.518595,35041.66656,percent of total billed charges,
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,AETNA [1000108],AETNA [100010801],,,76.8,,8027.88,0.518595,35041.66656,percent of total billed charges,
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA [1000108],AETNA [100010801],,,76.8,,1994.69,0.518595,35041.66656,percent of total billed charges,
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,AETNA [1000108],AETNA [100010801],,,76.8,,6551.38,0.518595,35041.66656,percent of total billed charges,
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,AETNA [1000108],AETNA [100010801],,,76.8,,1327.07,0.518595,35041.66656,percent of total billed charges,
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,AETNA [1000108],AETNA [100010801],,,76.8,,1327.07,0.518595,35041.66656,percent of total billed charges,
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,AETNA [1000108],AETNA [100010801],,,76.8,,707.5,0.518595,35041.66656,percent of total billed charges,
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.518595,35041.66656,percent of total billed charges,
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,AETNA [1000108],AETNA [100010801],,,76.8,,5378,0.518595,35041.66656,percent of total billed charges,
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,76.8,,253.78,0.518595,35041.66656,percent of total billed charges,
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA [1000108],AETNA [100010801],,,76.8,,16824.35,0.518595,35041.66656,percent of total billed charges,
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA [1000108],AETNA [100010801],,,76.8,,16824.35,0.518595,35041.66656,percent of total billed charges,
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA [1000108],AETNA [100010801],,,76.8,,16824.35,0.518595,35041.66656,percent of total billed charges,
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA [1000108],AETNA [100010801],,,76.8,,16824.35,0.518595,35041.66656,percent of total billed charges,
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,AETNA [1000108],AETNA [100010801],,,76.8,,4605.52,0.518595,35041.66656,percent of total billed charges,
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,0.518595,35041.66656,percent of total billed charges,
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,AETNA [1000108],AETNA [100010801],,,76.8,,4559.89,0.518595,35041.66656,percent of total billed charges,
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,AETNA [1000108],AETNA [100010801],,,76.8,,4605.52,0.518595,35041.66656,percent of total billed charges,
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,0.518595,35041.66656,percent of total billed charges,
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,0.518595,35041.66656,percent of total billed charges,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,76.8,,313.69,0.518595,35041.66656,percent of total billed charges,
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,AETNA [1000108],AETNA [100010801],,,76.8,,53.55,0.518595,35041.66656,percent of total billed charges,
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,AETNA [1000108],AETNA [100010801],,,76.8,,850.05,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,76.8,,2364.85,0.518595,35041.66656,percent of total billed charges,
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,76.8,,2364.85,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,AETNA [1000108],AETNA [100010801],,,76.8,,3529.92,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA [1000108],AETNA [100010801],,,76.8,,2309.85,0.518595,35041.66656,percent of total billed charges,
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,AETNA [1000108],AETNA [100010801],,,76.8,,895.57,0.518595,35041.66656,percent of total billed charges,
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,0.518595,35041.66656,percent of total billed charges,
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,AETNA [1000108],AETNA [100010801],,,76.8,,882.71,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,AETNA [1000108],AETNA [100010801],,,76.8,,1650.42,0.518595,35041.66656,percent of total billed charges,
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,AETNA [1000108],AETNA [100010801],,,76.8,,14.02,0.518595,35041.66656,percent of total billed charges,
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,AETNA [1000108],AETNA [100010801],,,76.8,,557.92,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,AETNA [1000108],AETNA [100010801],,,76.8,,2942.28,0.518595,35041.66656,percent of total billed charges,
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,0.518595,35041.66656,percent of total billed charges,
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,AETNA [1000108],AETNA [100010801],,,76.8,,5241.1,0.518595,35041.66656,percent of total billed charges,
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,AETNA [1000108],AETNA [100010801],,,76.8,,4621.82,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA [1000108],AETNA [100010801],,,76.8,,3951.13,0.518595,35041.66656,percent of total billed charges,
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA [1000108],AETNA [100010801],,,76.8,,3951.13,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA [1000108],AETNA [100010801],,,76.8,,3951.13,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA [1000108],AETNA [100010801],,,76.8,,3951.13,0.518595,35041.66656,percent of total billed charges,
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,AETNA [1000108],AETNA [100010801],,,76.8,,3505.66,0.518595,35041.66656,percent of total billed charges,
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,AETNA [1000108],AETNA [100010801],,,76.8,,4582.7,0.518595,35041.66656,percent of total billed charges,
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA [1000108],AETNA [100010801],,,76.8,,505.22,0.518595,35041.66656,percent of total billed charges,
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA [1000108],AETNA [100010801],,,76.8,,505.22,0.518595,35041.66656,percent of total billed charges,
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA [1000108],AETNA [100010801],,,76.8,,505.22,0.518595,35041.66656,percent of total billed charges,
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,76.8,,49.3,0.518595,35041.66656,percent of total billed charges,
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,AETNA [1000108],AETNA [100010801],,,76.8,,179.25,0.518595,35041.66656,percent of total billed charges,
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,AETNA [1000108],AETNA [100010801],,,76.8,,3595.11,0.518595,35041.66656,percent of total billed charges,
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,AETNA [1000108],AETNA [100010801],,,76.8,,4022.09,0.518595,35041.66656,percent of total billed charges,
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,AETNA [1000108],AETNA [100010801],,,76.8,,3881.93,0.518595,35041.66656,percent of total billed charges,
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,AETNA [1000108],AETNA [100010801],,,76.8,,3529.92,0.518595,35041.66656,percent of total billed charges,
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,AETNA [1000108],AETNA [100010801],,,76.8,,9100.55,0.518595,35041.66656,percent of total billed charges,
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA [1000108],AETNA [100010801],,,76.8,,822.3,0.518595,35041.66656,percent of total billed charges,
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA [1000108],AETNA [100010801],,,76.8,,822.3,0.518595,35041.66656,percent of total billed charges,
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,AETNA [1000108],AETNA [100010801],,,76.8,,4964.05,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,AETNA [1000108],AETNA [100010801],,,76.8,,24653.26,0.518595,35041.66656,percent of total billed charges,
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,AETNA [1000108],AETNA [100010801],,,76.8,,3550.94,0.518595,35041.66656,percent of total billed charges,
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,AETNA [1000108],AETNA [100010801],,,76.8,,4370.68,0.518595,35041.66656,percent of total billed charges,
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,AETNA [1000108],AETNA [100010801],,,76.8,,5598.01,0.518595,35041.66656,percent of total billed charges,
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,AETNA [1000108],AETNA [100010801],,,76.8,,4370.68,0.518595,35041.66656,percent of total billed charges,
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,0.518595,35041.66656,percent of total billed charges,
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,AETNA [1000108],AETNA [100010801],,,76.8,,4334.99,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,76.8,,291.29,0.518595,35041.66656,percent of total billed charges,
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,AETNA [1000108],AETNA [100010801],,,76.8,,418.95,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA [1000108],AETNA [100010801],,,76.8,,435.58,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA [1000108],AETNA [100010801],,,76.8,,435.58,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA [1000108],AETNA [100010801],,,76.8,,435.58,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,AETNA [1000108],AETNA [100010801],,,76.8,,410.4,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA [1000108],AETNA [100010801],,,76.8,,4380.63,0.518595,35041.66656,percent of total billed charges,
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA [1000108],AETNA [100010801],,,76.8,,4380.63,0.518595,35041.66656,percent of total billed charges,
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA [1000108],AETNA [100010801],,,76.8,,4380.63,0.518595,35041.66656,percent of total billed charges,
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,AETNA [1000108],AETNA [100010801],,,76.8,,5651.79,0.518595,35041.66656,percent of total billed charges,
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,AETNA [1000108],AETNA [100010801],,,76.8,,1442.35,0.518595,35041.66656,percent of total billed charges,
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,AETNA [1000108],AETNA [100010801],,,76.8,,1952.65,0.518595,35041.66656,percent of total billed charges,
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA [1000108],AETNA [100010801],,,76.8,,5738.49,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,AETNA [1000108],AETNA [100010801],,,76.8,,340.13,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA [1000108],AETNA [100010801],,,76.8,,6637.1,0.518595,35041.66656,percent of total billed charges,
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA [1000108],AETNA [100010801],,,76.8,,6637.1,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,AETNA [1000108],AETNA [100010801],,,76.8,,114.95,0.518595,35041.66656,percent of total billed charges,
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,AETNA [1000108],AETNA [100010801],,,76.8,,96.17,0.518595,35041.66656,percent of total billed charges,
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,AETNA [1000108],AETNA [100010801],,,76.8,,89.86,0.518595,35041.66656,percent of total billed charges,
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,AETNA [1000108],AETNA [100010801],,,76.8,,118.35,0.518595,35041.66656,percent of total billed charges,
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,AETNA [1000108],AETNA [100010801],,,76.8,,118.33,0.518595,35041.66656,percent of total billed charges,
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,AETNA [1000108],AETNA [100010801],,,76.8,,140.94,0.518595,35041.66656,percent of total billed charges,
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,AETNA [1000108],AETNA [100010801],,,76.8,,119.64,0.518595,35041.66656,percent of total billed charges,
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,AETNA [1000108],AETNA [100010801],,,76.8,,120.6,0.518595,35041.66656,percent of total billed charges,
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,AETNA [1000108],AETNA [100010801],,,76.8,,35.57,0.518595,35041.66656,percent of total billed charges,
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,AETNA [1000108],AETNA [100010801],,,76.8,,936.28,0.518595,35041.66656,percent of total billed charges,
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,AETNA [1000108],AETNA [100010801],,,76.8,,1408.49,0.518595,35041.66656,percent of total billed charges,
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,AETNA [1000108],AETNA [100010801],,,76.8,,1001.41,0.518595,35041.66656,percent of total billed charges,
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA [1000108],AETNA [100010801],,,76.8,,435.58,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,AETNA [1000108],AETNA [100010801],,,76.8,,410.4,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,AETNA [1000108],AETNA [100010801],,,76.8,,2070.77,0.518595,35041.66656,percent of total billed charges,
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA [1000108],AETNA [100010801],,,76.8,,1176.45,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,0.518595,35041.66656,percent of total billed charges,
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,AETNA [1000108],AETNA [100010801],,,76.8,,3532.98,0.518595,35041.66656,percent of total billed charges,
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA [1000108],AETNA [100010801],,,76.8,,4462.76,0.518595,35041.66656,percent of total billed charges,
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,0.518595,35041.66656,percent of total billed charges,
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,AETNA [1000108],AETNA [100010801],,,76.8,,954.19,0.518595,35041.66656,percent of total billed charges,
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA [1000108],AETNA [100010801],,,76.8,,5738.49,0.518595,35041.66656,percent of total billed charges,
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,AETNA [1000108],AETNA [100010801],,,76.8,,954.19,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,AETNA [1000108],AETNA [100010801],,,76.8,,5461.27,0.518595,35041.66656,percent of total billed charges,
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,AETNA [1000108],AETNA [100010801],,,76.8,,6763.24,0.518595,35041.66656,percent of total billed charges,
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,AETNA [1000108],AETNA [100010801],,,76.8,,509.7,0.518595,35041.66656,percent of total billed charges,
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA [1000108],AETNA [100010801],,,76.8,,902.09,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,AETNA [1000108],AETNA [100010801],,,76.8,,5558.89,0.518595,35041.66656,percent of total billed charges,
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,AETNA [1000108],AETNA [100010801],,,76.8,,509.7,0.518595,35041.66656,percent of total billed charges,
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA [1000108],AETNA [100010801],,,76.8,,777.37,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA [1000108],AETNA [100010801],,,76.8,,830.93,0.518595,35041.66656,percent of total billed charges,
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,AETNA [1000108],AETNA [100010801],,,76.8,,313.37,0.518595,35041.66656,percent of total billed charges,
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,AETNA [1000108],AETNA [100010801],,,76.8,,326.02,0.518595,35041.66656,percent of total billed charges,
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,AETNA [1000108],AETNA [100010801],,,76.8,,121.71,0.518595,35041.66656,percent of total billed charges,
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,AETNA [1000108],AETNA [100010801],,,76.8,,116.51,0.518595,35041.66656,percent of total billed charges,
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,AETNA [1000108],AETNA [100010801],,,76.8,,752.86,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,0.518595,35041.66656,percent of total billed charges,
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,AETNA [1000108],AETNA [100010801],,,76.8,,162.27,0.518595,35041.66656,percent of total billed charges,
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,AETNA [1000108],AETNA [100010801],,,76.8,,191.55,0.518595,35041.66656,percent of total billed charges,
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA [1000108],AETNA [100010801],,,76.8,,97.29,0.518595,35041.66656,percent of total billed charges,
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,AETNA [1000108],AETNA [100010801],,,76.8,,96.26,0.518595,35041.66656,percent of total billed charges,
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,AETNA [1000108],AETNA [100010801],,,76.8,,96.26,0.518595,35041.66656,percent of total billed charges,
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,AETNA [1000108],AETNA [100010801],,,76.8,,99.92,0.518595,35041.66656,percent of total billed charges,
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,AETNA [1000108],AETNA [100010801],,,76.8,,95.85,0.518595,35041.66656,percent of total billed charges,
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,AETNA [1000108],AETNA [100010801],,,76.8,,1018.11,0.518595,35041.66656,percent of total billed charges,
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA [1000108],AETNA [100010801],,,76.8,,97.29,0.518595,35041.66656,percent of total billed charges,
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA [1000108],AETNA [100010801],,,76.8,,97.29,0.518595,35041.66656,percent of total billed charges,
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,AETNA [1000108],AETNA [100010801],,,76.8,,104.59,0.518595,35041.66656,percent of total billed charges,
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,AETNA [1000108],AETNA [100010801],,,76.8,,69.73,0.518595,35041.66656,percent of total billed charges,
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,AETNA [1000108],AETNA [100010801],,,76.8,,1005.32,0.518595,35041.66656,percent of total billed charges,
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,AETNA [1000108],AETNA [100010801],,,76.8,,101.05,0.518595,35041.66656,percent of total billed charges,
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,AETNA [1000108],AETNA [100010801],,,76.8,,101.05,0.518595,35041.66656,percent of total billed charges,
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA [1000108],AETNA [100010801],,,76.8,,35041.67,0.518595,35041.66656,percent of total billed charges,
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,76.8,,197.18,0.518595,35041.66656,percent of total billed charges,
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,76.8,,197.18,0.518595,35041.66656,percent of total billed charges,
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,AETNA [1000108],AETNA [100010801],,,76.8,,264.4,0.518595,35041.66656,percent of total billed charges,
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,AETNA [1000108],AETNA [100010801],,,76.8,,246.47,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,0.518595,35041.66656,percent of total billed charges,
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,AETNA [1000108],AETNA [100010801],,,76.8,,12604,0.518595,35041.66656,percent of total billed charges,
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,AETNA [1000108],AETNA [100010801],,,76.8,,99.5,0.518595,35041.66656,percent of total billed charges,
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,AETNA [1000108],AETNA [100010801],,,76.8,,104.48,0.518595,35041.66656,percent of total billed charges,
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,AETNA [1000108],AETNA [100010801],,,,,,18.994945,416.02,other,272 with C codes
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,AETNA [1000108],AETNA [100010801],,,76.8,,34029.92,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA [1000108],AETNA [100010801],,,76.8,,23683.2,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA [1000108],AETNA [100010801],,,76.8,,26377.15,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA [1000108],AETNA [100010801],,,76.8,,26377.15,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA [1000108],AETNA [100010801],,,76.8,,26377.15,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA [1000108],AETNA [100010801],,,76.8,,26377.15,399.86,37344.8064,percent of total billed charges,
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA [1000108],AETNA [100010801],,,76.8,,28515.84,399.86,37344.8064,percent of total billed charges,
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA [1000108],AETNA [100010801],,,76.8,,28515.84,399.86,37344.8064,percent of total billed charges,
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,AETNA [1000108],AETNA [100010801],,,76.8,,20083.35,399.86,37344.8064,percent of total billed charges,
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,AETNA [1000108],AETNA [100010801],,,76.8,,20083.35,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,AETNA [1000108],AETNA [100010801],,,76.8,,19948.83,399.86,37344.8064,percent of total billed charges,
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,AETNA [1000108],AETNA [100010801],,,76.8,,28222.13,399.86,37344.8064,percent of total billed charges,
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,AETNA [1000108],AETNA [100010801],,,76.8,,19893.89,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,AETNA [1000108],AETNA [100010801],,,76.8,,19270.55,399.86,37344.8064,percent of total billed charges,
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,AETNA [1000108],AETNA [100010801],,,76.8,,19270.55,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,AETNA [1000108],AETNA [100010801],,,76.8,,37344.81,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,AETNA [1000108],AETNA [100010801],,,76.8,,27418.23,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,AETNA [1000108],AETNA [100010801],,,76.8,,24500.55,399.86,37344.8064,percent of total billed charges,
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,AETNA [1000108],AETNA [100010801],,,76.8,,19893.89,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,AETNA [1000108],AETNA [100010801],,,76.8,,26278.88,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,AETNA [1000108],AETNA [100010801],,,76.8,,28861.29,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,AETNA [1000108],AETNA [100010801],,,76.8,,25151.56,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,AETNA [1000108],AETNA [100010801],,,76.8,,25151.56,399.86,37344.8064,percent of total billed charges,
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,AETNA [1000108],AETNA [100010801],,,76.8,,21422.88,399.86,37344.8064,percent of total billed charges,
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,AETNA [1000108],AETNA [100010801],,,76.8,,21422.88,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,AETNA [1000108],AETNA [100010801],,,76.8,,24630.53,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,AETNA [1000108],AETNA [100010801],,,76.8,,24630.53,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,AETNA [1000108],AETNA [100010801],,,76.8,,28609.31,399.86,37344.8064,percent of total billed charges,
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,AETNA [1000108],AETNA [100010801],,,76.8,,26714.65,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,AETNA [1000108],AETNA [100010801],,,76.8,,26714.65,399.86,37344.8064,percent of total billed charges,
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,AETNA [1000108],AETNA [100010801],,,76.8,,29556.63,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,AETNA [1000108],AETNA [100010801],,,76.8,,35051.14,399.86,37344.8064,percent of total billed charges,
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,AETNA [1000108],AETNA [100010801],,,76.8,,25265.24,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,AETNA [1000108],AETNA [100010801],,,76.8,,33175.43,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,AETNA [1000108],AETNA [100010801],,,76.8,,32161.79,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,AETNA [1000108],AETNA [100010801],,,76.8,,19708.21,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,AETNA [1000108],AETNA [100010801],,,76.8,,35998.46,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,AETNA [1000108],AETNA [100010801],,,76.8,,28920.03,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,AETNA [1000108],AETNA [100010801],,,76.8,,23727.72,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA [1000108],AETNA [100010801],,,76.8,,21788.54,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA [1000108],AETNA [100010801],,,76.8,,21788.54,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA [1000108],AETNA [100010801],,,76.8,,23683.2,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA [1000108],AETNA [100010801],,,76.8,,23683.2,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,AETNA [1000108],AETNA [100010801],,,76.8,,27446.5,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,AETNA [1000108],AETNA [100010801],,,76.8,,18965.51,399.86,35998.464,percent of total billed charges,
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,AETNA [1000108],AETNA [100010801],,,76.8,,27446.5,399.86,35998.464,percent of total billed charges,
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,AETNA [1000108],AETNA [100010801],,,76.8,,35998.46,399.86,35998.464,percent of total billed charges,
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,AETNA [1000108],AETNA [100010801],,,76.8,,34103.81,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,AETNA [1000108],AETNA [100010801],,,76.8,,19325.49,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA [1000108],AETNA [100010801],,,76.8,,25664.26,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA [1000108],AETNA [100010801],,,76.8,,25664.26,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA [1000108],AETNA [100010801],,,76.8,,25664.26,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA [1000108],AETNA [100010801],,,76.8,,25664.26,399.86,35998.464,percent of total billed charges,
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,AETNA [1000108],AETNA [100010801],,,76.8,,27090.05,399.86,35998.464,percent of total billed charges,
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,AETNA [1000108],AETNA [100010801],,,76.8,,27090.05,399.86,35998.464,percent of total billed charges,
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,AETNA [1000108],AETNA [100010801],,,76.8,,27802.94,399.86,35998.464,percent of total billed charges,
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,AETNA [1000108],AETNA [100010801],,,76.8,,27802.94,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,AETNA [1000108],AETNA [100010801],,,76.8,,20462.28,399.86,35998.464,percent of total billed charges,
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA [1000108],AETNA [100010801],,,76.8,,28088.1,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,AETNA [1000108],AETNA [100010801],,,76.8,,26685.12,399.86,35998.464,percent of total billed charges,
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,AETNA [1000108],AETNA [100010801],,,76.8,,26685.12,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,AETNA [1000108],AETNA [100010801],,,76.8,,27418.23,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,AETNA [1000108],AETNA [100010801],,,76.8,,24500.55,399.86,35998.464,percent of total billed charges,
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA [1000108],AETNA [100010801],,,76.8,,28088.1,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,AETNA [1000108],AETNA [100010801],,,76.8,,22050.01,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,AETNA [1000108],AETNA [100010801],,,76.8,,22050.01,399.86,35998.464,percent of total billed charges,
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA [1000108],AETNA [100010801],,,76.8,,28088.1,399.86,35998.464,percent of total billed charges,
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,AETNA [1000108],AETNA [100010801],,,76.8,,19835.15,399.86,35998.464,percent of total billed charges,
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,AETNA [1000108],AETNA [100010801],,,76.8,,22286.84,399.86,35998.464,percent of total billed charges,
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,AETNA [1000108],AETNA [100010801],,,76.8,,32131.47,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,AETNA [1000108],AETNA [100010801],,,76.8,,21978.01,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,AETNA [1000108],AETNA [100010801],,,76.8,,21978.01,399.86,35998.464,percent of total billed charges,
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA [1000108],AETNA [100010801],,,76.8,,24441.06,399.86,35998.464,percent of total billed charges,
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA [1000108],AETNA [100010801],,,76.8,,24441.06,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA [1000108],AETNA [100010801],,,76.8,,24441.06,399.86,35998.464,percent of total billed charges,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA [1000108],AETNA [100010801],,,76.8,,24441.06,399.86,35998.464,percent of total billed charges,
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,AETNA [1000108],AETNA [100010801],,,,,,291.097925,929.69805,other,272 with C codes
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,1.322305,17969.99175,percent of total billed charges,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,1.322305,17969.99175,percent of total billed charges,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,AETNA [1000108],AETNA [100010801],,,76.8,,1697.52,12.50914,1945.83552,percent of total billed charges,
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,AETNA [1000108],AETNA [100010801],,,76.8,,1835.93,12.50914,1945.83552,percent of total billed charges,
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,AETNA [1000108],AETNA [100010801],,,76.8,,1945.84,12.50914,1945.83552,percent of total billed charges,
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,AETNA [1000108],AETNA [100010801],,,76.8,,196.55,12.50914,1945.83552,percent of total billed charges,
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,AETNA [1000108],AETNA [100010801],,,76.8,,281.38,12.50914,1945.83552,percent of total billed charges,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,AETNA [1000108],AETNA [100010801],,,76.8,,345.9,12.50914,1945.83552,percent of total billed charges,
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,AETNA [1000108],AETNA [100010801],,,76.8,,412.86,12.50914,1945.83552,percent of total billed charges,
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,AETNA [1000108],AETNA [100010801],,,76.8,,777.66,12.50914,1945.83552,percent of total billed charges,
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,AETNA [1000108],AETNA [100010801],,,76.8,,709.22,12.50914,1945.83552,percent of total billed charges,
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,AETNA [1000108],AETNA [100010801],,,76.8,,967.22,12.50914,1945.83552,percent of total billed charges,
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA [1000108],AETNA [100010801],,,76.8,,1044.6,12.50914,1945.83552,percent of total billed charges,
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA [1000108],AETNA [100010801],,,76.8,,1044.6,12.50914,1945.83552,percent of total billed charges,
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA [1000108],AETNA [100010801],,,76.8,,1044.6,12.50914,1945.83552,percent of total billed charges,
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA [1000108],AETNA [100010801],,,76.8,,1044.6,12.50914,1945.83552,percent of total billed charges,
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,AETNA [1000108],AETNA [100010801],,,76.8,,42.79,12.50914,1945.83552,percent of total billed charges,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,AETNA [1000108],AETNA [100010801],,,76.8,,883.93,12.50914,1945.83552,percent of total billed charges,
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,AETNA [1000108],AETNA [100010801],,,76.8,,1238.04,12.50914,1945.83552,percent of total billed charges,
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,AETNA [1000108],AETNA [100010801],,,76.8,,1238.04,12.50914,1945.83552,percent of total billed charges,
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,AETNA [1000108],AETNA [100010801],,,76.8,,1225.31,12.50914,1945.83552,percent of total billed charges,
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,AETNA [1000108],AETNA [100010801],,,76.8,,1298.58,12.50914,1945.83552,percent of total billed charges,
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA [1000108],AETNA [100010801],,,76.8,,1445.13,12.50914,1945.83552,percent of total billed charges,
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,AETNA [1000108],AETNA [100010801],,,76.8,,1103.19,12.50914,1945.83552,percent of total billed charges,
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,AETNA [1000108],AETNA [100010801],,,76.8,,1103.19,12.50914,1945.83552,percent of total billed charges,
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,12.50914,1945.83552,percent of total billed charges,
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA [1000108],AETNA [100010801],,,76.8,,369.48,10.327,9046.79424,percent of total billed charges,
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,AETNA [1000108],AETNA [100010801],,,76.8,,161.19,10.327,9046.79424,percent of total billed charges,
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,AETNA [1000108],AETNA [100010801],,,76.8,,107.69,10.327,9046.79424,percent of total billed charges,
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,AETNA [1000108],AETNA [100010801],,,76.8,,147.84,10.327,9046.79424,percent of total billed charges,
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,AETNA [1000108],AETNA [100010801],,,76.8,,35.33,10.327,9046.79424,percent of total billed charges,
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,AETNA [1000108],AETNA [100010801],,,76.8,,88.24,10.327,9046.79424,percent of total billed charges,
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,AETNA [1000108],AETNA [100010801],,,76.8,,122.29,10.327,9046.79424,percent of total billed charges,
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,AETNA [1000108],AETNA [100010801],,,76.8,,57.63,10.327,9046.79424,percent of total billed charges,
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,AETNA [1000108],AETNA [100010801],,,76.8,,70.7,10.327,9046.79424,percent of total billed charges,
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,AETNA [1000108],AETNA [100010801],,,76.8,,439.17,10.327,9046.79424,percent of total billed charges,
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,10.327,9046.79424,percent of total billed charges,
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA [1000108],AETNA [100010801],,,76.8,,2419.85,10.327,9046.79424,percent of total billed charges,
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA [1000108],AETNA [100010801],,,76.8,,2419.85,10.327,9046.79424,percent of total billed charges,
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,76.8,,3402.81,10.327,9046.79424,percent of total billed charges,
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,76.8,,3402.81,10.327,9046.79424,percent of total billed charges,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,AETNA [1000108],AETNA [100010801],,,76.8,,100.34,10.327,9046.79424,percent of total billed charges,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,AETNA [1000108],AETNA [100010801],,,76.8,,100.34,10.327,9046.79424,percent of total billed charges,
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,AETNA [1000108],AETNA [100010801],,,76.8,,65.68,10.327,9046.79424,percent of total billed charges,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,AETNA [1000108],AETNA [100010801],,,76.8,,397.89,10.327,9046.79424,percent of total billed charges,
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,AETNA [1000108],AETNA [100010801],,,76.8,,283.88,10.327,9046.79424,percent of total billed charges,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,AETNA [1000108],AETNA [100010801],,,76.8,,196.71,10.327,9046.79424,percent of total billed charges,
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,AETNA [1000108],AETNA [100010801],,,76.8,,9046.79,10.327,9046.79424,percent of total billed charges,
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,AETNA [1000108],AETNA [100010801],,,76.8,,62.11,10.327,9046.79424,percent of total billed charges,
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,AETNA [1000108],AETNA [100010801],,,,,,399.86,72522.399,other,272 with C codes
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,72522.399,other,272 with C codes
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,26.19915,3585.3312,percent of total billed charges,
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,26.19915,3585.3312,percent of total billed charges,
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,26.19915,3585.3312,percent of total billed charges,
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,26.19915,3585.3312,percent of total billed charges,
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,26.19915,3585.3312,percent of total billed charges,
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,26.19915,3585.3312,percent of total billed charges,
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,26.19915,3585.3312,percent of total billed charges,
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,26.19915,3585.3312,percent of total billed charges,
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,26.19915,3585.3312,percent of total billed charges,
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,26.19915,3585.3312,percent of total billed charges,
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,3585.3312,percent of total billed charges,
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,3585.3312,percent of total billed charges,
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,26.19915,3585.3312,percent of total billed charges,
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,26.19915,3585.3312,percent of total billed charges,
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,26.19915,3585.3312,percent of total billed charges,
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,26.19915,3585.3312,percent of total billed charges,
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,26.19915,3585.3312,percent of total billed charges,
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,26.19915,3585.3312,percent of total billed charges,
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,26.19915,3585.3312,percent of total billed charges,
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,26.19915,3585.3312,percent of total billed charges,
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,26.19915,3585.3312,percent of total billed charges,
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,76.8,,2658.16,26.19915,3585.3312,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,AETNA [1000108],AETNA [100010801],,,76.8,,4467.65,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,AETNA [1000108],AETNA [100010801],,,76.8,,13316.9,315.339435,23049.35424,percent of total billed charges,
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,AETNA [1000108],AETNA [100010801],,,76.8,,6642.64,315.339435,23049.35424,percent of total billed charges,
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA [1000108],AETNA [100010801],,,76.8,,9005.3,315.339435,23049.35424,percent of total billed charges,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,AETNA [1000108],AETNA [100010801],,,76.8,,23049.35,315.339435,23049.35424,percent of total billed charges,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,AETNA [1000108],AETNA [100010801],,,76.8,,19143.61,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,315.339435,23049.35424,percent of total billed charges,
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA [1000108],AETNA [100010801],,,76.8,,9005.3,315.339435,23049.35424,percent of total billed charges,
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA [1000108],AETNA [100010801],,,76.8,,9005.3,315.339435,23049.35424,percent of total billed charges,
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,AETNA [1000108],AETNA [100010801],,,76.8,,19447.8,315.339435,23049.35424,percent of total billed charges,
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA [1000108],AETNA [100010801],,,76.8,,9005.3,315.339435,23049.35424,percent of total billed charges,
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,AETNA [1000108],AETNA [100010801],,,76.8,,19447.8,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,AETNA [1000108],AETNA [100010801],,,76.8,,6433.06,315.339435,23049.35424,percent of total billed charges,
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,AETNA [1000108],AETNA [100010801],,,76.8,,6273.65,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,315.339435,23049.35424,percent of total billed charges,
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,AETNA [1000108],AETNA [100010801],,,76.8,,8426.43,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA [1000108],AETNA [100010801],,,76.8,,1078.76,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,315.339435,23049.35424,percent of total billed charges,
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,AETNA [1000108],AETNA [100010801],,,76.8,,7496.6,315.339435,23049.35424,percent of total billed charges,
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,AETNA [1000108],AETNA [100010801],,,76.8,,8258.19,315.339435,23049.35424,percent of total billed charges,
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,AETNA [1000108],AETNA [100010801],,,76.8,,20445.86,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,315.339435,23049.35424,percent of total billed charges,
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,AETNA [1000108],AETNA [100010801],,,76.8,,12646.78,315.339435,23049.35424,percent of total billed charges,
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,315.339435,23049.35424,percent of total billed charges,
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,AETNA [1000108],AETNA [100010801],,,76.8,,4045.66,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,AETNA [1000108],AETNA [100010801],,,76.8,,3506.43,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,AETNA [1000108],AETNA [100010801],,,76.8,,5442.89,315.339435,23049.35424,percent of total billed charges,
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,AETNA [1000108],AETNA [100010801],,,76.8,,8050.7,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,AETNA [1000108],AETNA [100010801],,,76.8,,2856.63,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,AETNA [1000108],AETNA [100010801],,,76.8,,2808.81,315.339435,23049.35424,percent of total billed charges,
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,AETNA [1000108],AETNA [100010801],,,76.8,,5726.29,315.339435,23049.35424,percent of total billed charges,
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,AETNA [1000108],AETNA [100010801],,,76.8,,6053.51,315.339435,23049.35424,percent of total billed charges,
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,315.339435,23049.35424,percent of total billed charges,
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,315.339435,23049.35424,percent of total billed charges,
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,315.339435,23049.35424,percent of total billed charges,
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,315.339435,23049.35424,percent of total billed charges,
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,315.339435,23049.35424,percent of total billed charges,
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,315.339435,23049.35424,percent of total billed charges,
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,AETNA [1000108],AETNA [100010801],,,76.8,,4840.2,315.339435,23049.35424,percent of total billed charges,
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,AETNA [1000108],AETNA [100010801],,,76.8,,23953.31,270.120645,23953.3056,percent of total billed charges,
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,AETNA [1000108],AETNA [100010801],,,76.8,,924.07,270.120645,23953.3056,percent of total billed charges,
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,270.120645,23953.3056,percent of total billed charges,
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,AETNA [1000108],AETNA [100010801],,,76.8,,1835.93,270.120645,23953.3056,percent of total billed charges,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,AETNA [1000108],AETNA [100010801],,,76.8,,6098.32,270.120645,23953.3056,percent of total billed charges,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,AETNA [1000108],AETNA [100010801],,,76.8,,7023.99,270.120645,23953.3056,percent of total billed charges,
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,AETNA [1000108],AETNA [100010801],,,76.8,,11624.66,270.120645,23953.3056,percent of total billed charges,
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,AETNA [1000108],AETNA [100010801],,,76.8,,6235.22,270.120645,23953.3056,percent of total billed charges,
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,AETNA [1000108],AETNA [100010801],,,76.8,,6235.22,270.120645,23953.3056,percent of total billed charges,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,AETNA [1000108],AETNA [100010801],,,76.8,,7619.44,270.120645,23953.3056,percent of total billed charges,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,AETNA [1000108],AETNA [100010801],,,76.8,,8083.29,270.120645,23953.3056,percent of total billed charges,
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,AETNA [1000108],AETNA [100010801],,,76.8,,7251.58,270.120645,23953.3056,percent of total billed charges,
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,AETNA [1000108],AETNA [100010801],,,76.8,,7773.42,270.120645,23953.3056,percent of total billed charges,
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,AETNA [1000108],AETNA [100010801],,,76.8,,7251.58,270.120645,23953.3056,percent of total billed charges,
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,270.120645,23953.3056,percent of total billed charges,
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,270.120645,23953.3056,percent of total billed charges,
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,270.120645,23953.3056,percent of total billed charges,
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,270.120645,23953.3056,percent of total billed charges,
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,AETNA [1000108],AETNA [100010801],,,76.8,,3894.97,270.120645,23953.3056,percent of total billed charges,
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,AETNA [1000108],AETNA [100010801],,,76.8,,6657.31,270.120645,23953.3056,percent of total billed charges,
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,AETNA [1000108],AETNA [100010801],,,76.8,,16082.93,270.120645,23953.3056,percent of total billed charges,
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,AETNA [1000108],AETNA [100010801],,,76.8,,2666.23,270.120645,23953.3056,percent of total billed charges,
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,AETNA [1000108],AETNA [100010801],,,76.8,,4035.13,270.120645,23953.3056,percent of total billed charges,
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,AETNA [1000108],AETNA [100010801],,,76.8,,4849.97,270.120645,23953.3056,percent of total billed charges,
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,AETNA [1000108],AETNA [100010801],,,76.8,,4035.13,270.120645,23953.3056,percent of total billed charges,
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,AETNA [1000108],AETNA [100010801],,,76.8,,12604,270.120645,23953.3056,percent of total billed charges,
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,14243.66592,percent of total billed charges,
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,76.8,,10251.45,399.86,14243.66592,percent of total billed charges,
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,AETNA [1000108],AETNA [100010801],,,76.8,,8714.44,399.86,14243.66592,percent of total billed charges,
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,14243.66592,percent of total billed charges,
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,14243.66592,percent of total billed charges,
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,AETNA [1000108],AETNA [100010801],,,76.8,,13545.02,399.86,14243.66592,percent of total billed charges,
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,AETNA [1000108],AETNA [100010801],,,76.8,,13245.61,399.86,14243.66592,percent of total billed charges,
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,AETNA [1000108],AETNA [100010801],,,76.8,,14243.67,399.86,14243.66592,percent of total billed charges,
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,14243.66592,percent of total billed charges,
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,14243.66592,percent of total billed charges,
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,AETNA [1000108],AETNA [100010801],,,76.8,,846.69,247.50227,1378.95936,percent of total billed charges,
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,AETNA [1000108],AETNA [100010801],,,76.8,,1298.99,247.50227,1378.95936,percent of total billed charges,
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,AETNA [1000108],AETNA [100010801],,,76.8,,1378.96,247.50227,1378.95936,percent of total billed charges,
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,AETNA [1000108],AETNA [100010801],,,76.8,,28230.68,399.86,39874.22976,percent of total billed charges,
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,76.8,,1526.55,399.86,39874.22976,percent of total billed charges,
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,AETNA [1000108],AETNA [100010801],,,76.8,,31034.47,399.86,39874.22976,percent of total billed charges,
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,AETNA [1000108],AETNA [100010801],,,76.8,,35316.39,399.86,39874.22976,percent of total billed charges,
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,AETNA [1000108],AETNA [100010801],,,76.8,,34558.53,399.86,39874.22976,percent of total billed charges,
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,AETNA [1000108],AETNA [100010801],,,76.8,,39874.23,399.86,39874.22976,percent of total billed charges,
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,AETNA [1000108],AETNA [100010801],,,76.8,,22735.87,399.86,39874.22976,percent of total billed charges,
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,AETNA [1000108],AETNA [100010801],,,76.8,,20745.28,399.86,39874.22976,percent of total billed charges,
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,AETNA [1000108],AETNA [100010801],,,76.8,,38751.4,399.86,39874.22976,percent of total billed charges,
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,AETNA [1000108],AETNA [100010801],,,76.8,,25009.46,399.86,39874.22976,percent of total billed charges,
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,AETNA [1000108],AETNA [100010801],,,76.8,,34081.08,399.86,39874.22976,percent of total billed charges,
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,AETNA [1000108],AETNA [100010801],,,76.8,,20359.97,399.86,39874.22976,percent of total billed charges,
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,AETNA [1000108],AETNA [100010801],,,76.8,,452.61,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,AETNA [1000108],AETNA [100010801],,,76.8,,1533.22,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA [1000108],AETNA [100010801],,,76.8,,2018.9,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA [1000108],AETNA [100010801],,,76.8,,2018.9,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA [1000108],AETNA [100010801],,,76.8,,2018.9,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,AETNA [1000108],AETNA [100010801],,,76.8,,1982.47,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,AETNA [1000108],AETNA [100010801],,,76.8,,4130.04,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,AETNA [1000108],AETNA [100010801],,,76.8,,4838.34,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,AETNA [1000108],AETNA [100010801],,,76.8,,1392.21,51.089465,30693.4272,percent of total billed charges,
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,AETNA [1000108],AETNA [100010801],,,76.8,,1606.53,51.089465,30693.4272,percent of total billed charges,
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,AETNA [1000108],AETNA [100010801],,,76.8,,174.77,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,AETNA [1000108],AETNA [100010801],,,76.8,,3927.86,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,AETNA [1000108],AETNA [100010801],,,76.8,,3625.71,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,AETNA [1000108],AETNA [100010801],,,76.8,,7186.96,51.089465,30693.4272,percent of total billed charges,
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,AETNA [1000108],AETNA [100010801],,,76.8,,4834.27,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,AETNA [1000108],AETNA [100010801],,,76.8,,7990.07,51.089465,30693.4272,percent of total billed charges,
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,AETNA [1000108],AETNA [100010801],,,76.8,,30693.43,51.089465,30693.4272,percent of total billed charges,
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA [1000108],AETNA [100010801],,,76.8,,30123.13,51.089465,30693.4272,percent of total billed charges,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,AETNA [1000108],AETNA [100010801],,,76.8,,11477.63,51.089465,30693.4272,percent of total billed charges,
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA [1000108],AETNA [100010801],,,76.8,,30123.13,51.089465,30693.4272,percent of total billed charges,
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA [1000108],AETNA [100010801],,,76.8,,30123.13,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,51.089465,30693.4272,percent of total billed charges,
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,AETNA [1000108],AETNA [100010801],,,76.8,,23092.12,51.089465,30693.4272,percent of total billed charges,
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,AETNA [1000108],AETNA [100010801],,,76.8,,865.11,51.089465,30693.4272,percent of total billed charges,
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,AETNA [1000108],AETNA [100010801],,,76.8,,1271.22,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,AETNA [1000108],AETNA [100010801],,,76.8,,5127.02,51.089465,30693.4272,percent of total billed charges,
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,51.089465,30693.4272,percent of total billed charges,
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,AETNA [1000108],AETNA [100010801],,,76.8,,3660.3,51.089465,30693.4272,percent of total billed charges,
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,AETNA [1000108],AETNA [100010801],,,76.8,,4348.03,51.089465,30693.4272,percent of total billed charges,
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,AETNA [1000108],AETNA [100010801],,,76.8,,13291.23,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,AETNA [1000108],AETNA [100010801],,,76.8,,6636.09,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,AETNA [1000108],AETNA [100010801],,,76.8,,1622.17,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,AETNA [1000108],AETNA [100010801],,,76.8,,8415.02,51.089465,30693.4272,percent of total billed charges,
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,AETNA [1000108],AETNA [100010801],,,76.8,,8415.02,51.089465,30693.4272,percent of total billed charges,
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,AETNA [1000108],AETNA [100010801],,,76.8,,8668.82,51.089465,30693.4272,percent of total billed charges,
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,AETNA [1000108],AETNA [100010801],,,76.8,,7990.07,51.089465,30693.4272,percent of total billed charges,
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,AETNA [1000108],AETNA [100010801],,,76.8,,1443.1,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,AETNA [1000108],AETNA [100010801],,,76.8,,1443.1,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,AETNA [1000108],AETNA [100010801],,,76.8,,1949.5,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,AETNA [1000108],AETNA [100010801],,,76.8,,1949.5,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,AETNA [1000108],AETNA [100010801],,,76.8,,1899.58,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,AETNA [1000108],AETNA [100010801],,,76.8,,2030.8,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,AETNA [1000108],AETNA [100010801],,,76.8,,2030.8,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,AETNA [1000108],AETNA [100010801],,,76.8,,1998.96,51.089465,30693.4272,percent of total billed charges,
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,AETNA [1000108],AETNA [100010801],,,76.8,,2364.93,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,AETNA [1000108],AETNA [100010801],,,76.8,,3021.14,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,AETNA [1000108],AETNA [100010801],,,76.8,,4338.25,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,AETNA [1000108],AETNA [100010801],,,76.8,,3021.14,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,AETNA [1000108],AETNA [100010801],,,76.8,,2614.16,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,AETNA [1000108],AETNA [100010801],,,76.8,,3305.03,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,AETNA [1000108],AETNA [100010801],,,76.8,,3072.47,51.089465,30693.4272,percent of total billed charges,
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,AETNA [1000108],AETNA [100010801],,,76.8,,4129.65,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,AETNA [1000108],AETNA [100010801],,,76.8,,3369.45,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,AETNA [1000108],AETNA [100010801],,,76.8,,5400.81,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,AETNA [1000108],AETNA [100010801],,,76.8,,2482.18,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,AETNA [1000108],AETNA [100010801],,,76.8,,4093.79,51.089465,30693.4272,percent of total billed charges,
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,AETNA [1000108],AETNA [100010801],,,76.8,,23048.49,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,AETNA [1000108],AETNA [100010801],,,76.8,,5375.39,51.089465,30693.4272,percent of total billed charges,
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,AETNA [1000108],AETNA [100010801],,,76.8,,3549.1,51.089465,30693.4272,percent of total billed charges,
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,144.095325,460.20645,other,272 with C codes
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,AETNA [1000108],AETNA [100010801],,,76.8,,15486.38,248.891925,15486.38208,percent of total billed charges,
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,AETNA [1000108],AETNA [100010801],,,76.8,,4766.86,248.891925,15486.38208,percent of total billed charges,
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,AETNA [1000108],AETNA [100010801],,,76.8,,13844.44,248.891925,15486.38208,percent of total billed charges,
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,AETNA [1000108],AETNA [100010801],,,76.8,,4318.69,248.891925,15486.38208,percent of total billed charges,
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,AETNA [1000108],AETNA [100010801],,,76.8,,5052.25,248.891925,15486.38208,percent of total billed charges,
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,AETNA [1000108],AETNA [100010801],,,76.8,,3692.04,248.891925,15486.38208,percent of total billed charges,
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,AETNA [1000108],AETNA [100010801],,,76.8,,3813.49,248.891925,15486.38208,percent of total billed charges,
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,AETNA [1000108],AETNA [100010801],,,76.8,,3625,248.891925,15486.38208,percent of total billed charges,
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,248.891925,15486.38208,percent of total billed charges,
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,248.891925,15486.38208,percent of total billed charges,
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,AETNA [1000108],AETNA [100010801],,,76.8,,2743.23,248.891925,15486.38208,percent of total billed charges,
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,AETNA [1000108],AETNA [100010801],,,76.8,,3545.73,248.891925,15486.38208,percent of total billed charges,
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,AETNA [1000108],AETNA [100010801],,,76.8,,3545.73,248.891925,15486.38208,percent of total billed charges,
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,AETNA [1000108],AETNA [100010801],,,76.8,,3409.37,248.891925,15486.38208,percent of total billed charges,
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,AETNA [1000108],AETNA [100010801],,,76.8,,3394.56,248.891925,15486.38208,percent of total billed charges,
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,AETNA [1000108],AETNA [100010801],,,76.8,,3863.52,248.891925,15486.38208,percent of total billed charges,
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,AETNA [1000108],AETNA [100010801],,,76.8,,22341.78,399.86,23012.49024,percent of total billed charges,
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,AETNA [1000108],AETNA [100010801],,,76.8,,22341.78,399.86,23012.49024,percent of total billed charges,
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,AETNA [1000108],AETNA [100010801],,,76.8,,23012.49,399.86,23012.49024,percent of total billed charges,
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,AETNA [1000108],AETNA [100010801],,,76.8,,23012.49,399.86,23012.49024,percent of total billed charges,
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,AETNA [1000108],AETNA [100010801],,,76.8,,6746.94,9.170825,27238.33344,percent of total billed charges,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,76.8,,304.73,9.170825,27238.33344,percent of total billed charges,
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,AETNA [1000108],AETNA [100010801],,,76.8,,5269.42,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,AETNA [1000108],AETNA [100010801],,,76.8,,14190.62,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA [1000108],AETNA [100010801],,,76.8,,8037.66,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA [1000108],AETNA [100010801],,,76.8,,8037.66,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,AETNA [1000108],AETNA [100010801],,,76.8,,12183.25,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,AETNA [1000108],AETNA [100010801],,,76.8,,14902.38,9.170825,27238.33344,percent of total billed charges,
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,AETNA [1000108],AETNA [100010801],,,76.8,,14902.38,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,AETNA [1000108],AETNA [100010801],,,76.8,,2480.34,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,AETNA [1000108],AETNA [100010801],,,76.8,,3472.48,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,AETNA [1000108],AETNA [100010801],,,76.8,,12475.68,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,AETNA [1000108],AETNA [100010801],,,76.8,,9300.44,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,AETNA [1000108],AETNA [100010801],,,76.8,,8340.89,9.170825,27238.33344,percent of total billed charges,
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA [1000108],AETNA [100010801],,,76.8,,4145.95,9.170825,27238.33344,percent of total billed charges,
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA [1000108],AETNA [100010801],,,76.8,,4145.95,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA [1000108],AETNA [100010801],,,76.8,,4145.95,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,AETNA [1000108],AETNA [100010801],,,76.8,,7446.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,AETNA [1000108],AETNA [100010801],,,76.8,,3562.51,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,AETNA [1000108],AETNA [100010801],,,76.8,,6218.92,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,AETNA [1000108],AETNA [100010801],,,76.8,,6218.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,AETNA [1000108],AETNA [100010801],,,76.8,,5345.4,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA [1000108],AETNA [100010801],,,76.8,,10898.76,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA [1000108],AETNA [100010801],,,76.8,,10898.76,9.170825,27238.33344,percent of total billed charges,
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,AETNA [1000108],AETNA [100010801],,,76.8,,12735.18,9.170825,27238.33344,percent of total billed charges,
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA [1000108],AETNA [100010801],,,76.8,,3324.58,9.170825,27238.33344,percent of total billed charges,
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA [1000108],AETNA [100010801],,,76.8,,3324.58,9.170825,27238.33344,percent of total billed charges,
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA [1000108],AETNA [100010801],,,76.8,,3324.58,9.170825,27238.33344,percent of total billed charges,
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,AETNA [1000108],AETNA [100010801],,,76.8,,3776,9.170825,27238.33344,percent of total billed charges,
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA [1000108],AETNA [100010801],,,76.8,,3324.58,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,9.170825,27238.33344,percent of total billed charges,
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA [1000108],AETNA [100010801],,,76.8,,16527.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA [1000108],AETNA [100010801],,,76.8,,16527.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA [1000108],AETNA [100010801],,,76.8,,16527.78,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA [1000108],AETNA [100010801],,,76.8,,2419.85,9.170825,27238.33344,percent of total billed charges,
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,AETNA [1000108],AETNA [100010801],,,76.8,,7511.27,9.170825,27238.33344,percent of total billed charges,
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,AETNA [1000108],AETNA [100010801],,,76.8,,7511.27,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,AETNA [1000108],AETNA [100010801],,,76.8,,11240.95,9.170825,27238.33344,percent of total billed charges,
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,AETNA [1000108],AETNA [100010801],,,76.8,,16322.47,9.170825,27238.33344,percent of total billed charges,
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,AETNA [1000108],AETNA [100010801],,,76.8,,12769.39,9.170825,27238.33344,percent of total billed charges,
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,AETNA [1000108],AETNA [100010801],,,76.8,,10642.11,9.170825,27238.33344,percent of total billed charges,
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,9.170825,27238.33344,percent of total billed charges,
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,9.170825,27238.33344,percent of total billed charges,
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,9.170825,27238.33344,percent of total billed charges,
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,AETNA [1000108],AETNA [100010801],,,76.8,,10642.11,9.170825,27238.33344,percent of total billed charges,
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,AETNA [1000108],AETNA [100010801],,,76.8,,7988,9.170825,27238.33344,percent of total billed charges,
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,AETNA [1000108],AETNA [100010801],,,76.8,,568.57,9.170825,27238.33344,percent of total billed charges,
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,AETNA [1000108],AETNA [100010801],,,76.8,,6323.22,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,AETNA [1000108],AETNA [100010801],,,76.8,,281.87,9.170825,27238.33344,percent of total billed charges,
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,AETNA [1000108],AETNA [100010801],,,76.8,,591.53,9.170825,27238.33344,percent of total billed charges,
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA [1000108],AETNA [100010801],,,76.8,,3963.42,9.170825,27238.33344,percent of total billed charges,
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA [1000108],AETNA [100010801],,,76.8,,3963.42,9.170825,27238.33344,percent of total billed charges,
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA [1000108],AETNA [100010801],,,76.8,,3963.42,9.170825,27238.33344,percent of total billed charges,
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,AETNA [1000108],AETNA [100010801],,,76.8,,20271.91,9.170825,27238.33344,percent of total billed charges,
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,AETNA [1000108],AETNA [100010801],,,76.8,,5280.22,9.170825,27238.33344,percent of total billed charges,
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,9.170825,27238.33344,percent of total billed charges,
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA [1000108],AETNA [100010801],,,76.8,,5575.19,9.170825,27238.33344,percent of total billed charges,
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA [1000108],AETNA [100010801],,,76.8,,5575.19,9.170825,27238.33344,percent of total billed charges,
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,AETNA [1000108],AETNA [100010801],,,76.8,,17420.33,9.170825,27238.33344,percent of total billed charges,
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,AETNA [1000108],AETNA [100010801],,,76.8,,200.18,9.170825,27238.33344,percent of total billed charges,
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,AETNA [1000108],AETNA [100010801],,,76.8,,4863.01,9.170825,27238.33344,percent of total billed charges,
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,AETNA [1000108],AETNA [100010801],,,76.8,,5602.9,9.170825,27238.33344,percent of total billed charges,
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,AETNA [1000108],AETNA [100010801],,,76.8,,5765.87,9.170825,27238.33344,percent of total billed charges,
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,9.170825,27238.33344,percent of total billed charges,
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,AETNA [1000108],AETNA [100010801],,,76.8,,2830.49,9.170825,27238.33344,percent of total billed charges,
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,AETNA [1000108],AETNA [100010801],,,76.8,,3722.84,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,AETNA [1000108],AETNA [100010801],,,76.8,,3834.55,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,AETNA [1000108],AETNA [100010801],,,76.8,,3834.55,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,AETNA [1000108],AETNA [100010801],,,76.8,,4713.9,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,AETNA [1000108],AETNA [100010801],,,76.8,,4773.22,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,AETNA [1000108],AETNA [100010801],,,76.8,,3722.84,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,AETNA [1000108],AETNA [100010801],,,76.8,,3614.44,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,AETNA [1000108],AETNA [100010801],,,76.8,,12318.84,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA [1000108],AETNA [100010801],,,76.8,,7909.76,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA [1000108],AETNA [100010801],,,76.8,,7909.76,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,AETNA [1000108],AETNA [100010801],,,76.8,,8071.41,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA [1000108],AETNA [100010801],,,76.8,,7909.76,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,AETNA [1000108],AETNA [100010801],,,76.8,,10074.36,9.170825,27238.33344,percent of total billed charges,
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,AETNA [1000108],AETNA [100010801],,,76.8,,10074.36,9.170825,27238.33344,percent of total billed charges,
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA [1000108],AETNA [100010801],,,76.8,,4155.72,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,AETNA [1000108],AETNA [100010801],,,76.8,,8198.31,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,AETNA [1000108],AETNA [100010801],,,76.8,,7496.6,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA [1000108],AETNA [100010801],,,76.8,,8164.94,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA [1000108],AETNA [100010801],,,76.8,,8164.94,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA [1000108],AETNA [100010801],,,76.8,,8164.94,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA [1000108],AETNA [100010801],,,76.8,,8164.94,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA [1000108],AETNA [100010801],,,76.8,,21466.72,9.170825,27238.33344,percent of total billed charges,
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA [1000108],AETNA [100010801],,,76.8,,21466.72,9.170825,27238.33344,percent of total billed charges,
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA [1000108],AETNA [100010801],,,76.8,,21466.72,9.170825,27238.33344,percent of total billed charges,
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA [1000108],AETNA [100010801],,,76.8,,21466.72,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,9.170825,27238.33344,percent of total billed charges,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,AETNA [1000108],AETNA [100010801],,,76.8,,879.23,9.170825,27238.33344,percent of total billed charges,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,AETNA [1000108],AETNA [100010801],,,76.8,,879.23,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,AETNA [1000108],AETNA [100010801],,,76.8,,1485.02,9.170825,27238.33344,percent of total billed charges,
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,AETNA [1000108],AETNA [100010801],,,76.8,,1974.33,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,AETNA [1000108],AETNA [100010801],,,76.8,,3383.58,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,AETNA [1000108],AETNA [100010801],,,76.8,,6576.8,9.170825,27238.33344,percent of total billed charges,
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,AETNA [1000108],AETNA [100010801],,,76.8,,3383.58,9.170825,27238.33344,percent of total billed charges,
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,AETNA [1000108],AETNA [100010801],,,76.8,,9305.86,9.170825,27238.33344,percent of total billed charges,
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,AETNA [1000108],AETNA [100010801],,,76.8,,3446.45,9.170825,27238.33344,percent of total billed charges,
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA [1000108],AETNA [100010801],,,76.8,,2144.86,9.170825,27238.33344,percent of total billed charges,
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA [1000108],AETNA [100010801],,,76.8,,5534.45,9.170825,27238.33344,percent of total billed charges,
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA [1000108],AETNA [100010801],,,76.8,,5534.45,9.170825,27238.33344,percent of total billed charges,
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,AETNA [1000108],AETNA [100010801],,,76.8,,872.46,9.170825,27238.33344,percent of total billed charges,
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA [1000108],AETNA [100010801],,,76.8,,5534.45,9.170825,27238.33344,percent of total billed charges,
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,AETNA [1000108],AETNA [100010801],,,76.8,,4473.52,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,AETNA [1000108],AETNA [100010801],,,76.8,,4473.52,9.170825,27238.33344,percent of total billed charges,
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA [1000108],AETNA [100010801],,,76.8,,7368.49,9.170825,27238.33344,percent of total billed charges,
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA [1000108],AETNA [100010801],,,76.8,,7368.49,9.170825,27238.33344,percent of total billed charges,
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA [1000108],AETNA [100010801],,,76.8,,7368.49,9.170825,27238.33344,percent of total billed charges,
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,AETNA [1000108],AETNA [100010801],,,76.8,,8007.24,9.170825,27238.33344,percent of total billed charges,
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA [1000108],AETNA [100010801],,,76.8,,9444.45,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA [1000108],AETNA [100010801],,,76.8,,9444.45,9.170825,27238.33344,percent of total billed charges,
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA [1000108],AETNA [100010801],,,76.8,,9444.45,9.170825,27238.33344,percent of total billed charges,
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA [1000108],AETNA [100010801],,,76.8,,9444.45,9.170825,27238.33344,percent of total billed charges,
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,AETNA [1000108],AETNA [100010801],,,76.8,,5736.53,9.170825,27238.33344,percent of total billed charges,
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,AETNA [1000108],AETNA [100010801],,,76.8,,5736.53,9.170825,27238.33344,percent of total billed charges,
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,AETNA [1000108],AETNA [100010801],,,76.8,,14828.24,9.170825,27238.33344,percent of total billed charges,
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,AETNA [1000108],AETNA [100010801],,,76.8,,15695.12,9.170825,27238.33344,percent of total billed charges,
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA [1000108],AETNA [100010801],,,76.8,,5684.38,9.170825,27238.33344,percent of total billed charges,
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA [1000108],AETNA [100010801],,,76.8,,5684.38,9.170825,27238.33344,percent of total billed charges,
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,AETNA [1000108],AETNA [100010801],,,76.8,,18627.97,9.170825,27238.33344,percent of total billed charges,
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,AETNA [1000108],AETNA [100010801],,,76.8,,20689.64,9.170825,27238.33344,percent of total billed charges,
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,AETNA [1000108],AETNA [100010801],,,76.8,,20689.64,9.170825,27238.33344,percent of total billed charges,
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,AETNA [1000108],AETNA [100010801],,,76.8,,27238.33,9.170825,27238.33344,percent of total billed charges,
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,AETNA [1000108],AETNA [100010801],,,76.8,,1921.41,9.170825,27238.33344,percent of total billed charges,
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,AETNA [1000108],AETNA [100010801],,,76.8,,1335.21,9.170825,27238.33344,percent of total billed charges,
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,AETNA [1000108],AETNA [100010801],,,76.8,,2610.5,9.170825,27238.33344,percent of total billed charges,
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,AETNA [1000108],AETNA [100010801],,,76.8,,5371.48,9.170825,27238.33344,percent of total billed charges,
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,AETNA [1000108],AETNA [100010801],,,76.8,,9253.39,9.170825,27238.33344,percent of total billed charges,
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,AETNA [1000108],AETNA [100010801],,,76.8,,14083.98,9.170825,27238.33344,percent of total billed charges,
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,AETNA [1000108],AETNA [100010801],,,76.8,,10360.66,9.170825,27238.33344,percent of total billed charges,
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,AETNA [1000108],AETNA [100010801],,,76.8,,3397.1,9.170825,27238.33344,percent of total billed charges,
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,AETNA [1000108],AETNA [100010801],,,76.8,,5369.03,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,76.8,,1815.57,9.170825,27238.33344,percent of total billed charges,
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA [1000108],AETNA [100010801],,,76.8,,4481.66,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,AETNA [1000108],AETNA [100010801],,,76.8,,14970.82,9.170825,27238.33344,percent of total billed charges,
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,AETNA [1000108],AETNA [100010801],,,76.8,,2889.7,9.170825,27238.33344,percent of total billed charges,
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,AETNA [1000108],AETNA [100010801],,,76.8,,7362.79,9.170825,27238.33344,percent of total billed charges,
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,AETNA [1000108],AETNA [100010801],,,76.8,,3943.86,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,AETNA [1000108],AETNA [100010801],,,76.8,,3943.86,9.170825,27238.33344,percent of total billed charges,
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,AETNA [1000108],AETNA [100010801],,,76.8,,6763.24,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,AETNA [1000108],AETNA [100010801],,,76.8,,10060.39,9.170825,27238.33344,percent of total billed charges,
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,AETNA [1000108],AETNA [100010801],,,76.8,,20538.07,9.170825,27238.33344,percent of total billed charges,
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,AETNA [1000108],AETNA [100010801],,,76.8,,21902.22,9.170825,27238.33344,percent of total billed charges,
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,AETNA [1000108],AETNA [100010801],,,76.8,,10493.83,9.170825,27238.33344,percent of total billed charges,
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,AETNA [1000108],AETNA [100010801],,,76.8,,2405.18,9.170825,27238.33344,percent of total billed charges,
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,AETNA [1000108],AETNA [100010801],,,76.8,,2610.5,9.170825,27238.33344,percent of total billed charges,
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,AETNA [1000108],AETNA [100010801],,,76.8,,27238.33,9.170825,27238.33344,percent of total billed charges,
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,AETNA [1000108],AETNA [100010801],,,76.8,,16653.25,9.170825,27238.33344,percent of total billed charges,
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,AETNA [1000108],AETNA [100010801],,,76.8,,22826.82,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,AETNA [1000108],AETNA [100010801],,,76.8,,2093.68,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,AETNA [1000108],AETNA [100010801],,,76.8,,3556.44,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,AETNA [1000108],AETNA [100010801],,,76.8,,3556.44,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,AETNA [1000108],AETNA [100010801],,,76.8,,1139.82,9.170825,27238.33344,percent of total billed charges,
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,AETNA [1000108],AETNA [100010801],,,76.8,,4263.28,9.170825,27238.33344,percent of total billed charges,
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,AETNA [1000108],AETNA [100010801],,,76.8,,7476.86,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,AETNA [1000108],AETNA [100010801],,,76.8,,7339.98,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,AETNA [1000108],AETNA [100010801],,,76.8,,8914.05,9.170825,27238.33344,percent of total billed charges,
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,AETNA [1000108],AETNA [100010801],,,76.8,,3541.77,9.170825,27238.33344,percent of total billed charges,
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,AETNA [1000108],AETNA [100010801],,,76.8,,3541.77,9.170825,27238.33344,percent of total billed charges,
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA [1000108],AETNA [100010801],,,76.8,,4087.28,9.170825,27238.33344,percent of total billed charges,
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA [1000108],AETNA [100010801],,,76.8,,4087.28,9.170825,27238.33344,percent of total billed charges,
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA [1000108],AETNA [100010801],,,76.8,,4087.28,9.170825,27238.33344,percent of total billed charges,
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,AETNA [1000108],AETNA [100010801],,,76.8,,22841.19,9.170825,27238.33344,percent of total billed charges,
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,AETNA [1000108],AETNA [100010801],,,76.8,,22841.19,9.170825,27238.33344,percent of total billed charges,
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,9.170825,27238.33344,percent of total billed charges,
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,AETNA [1000108],AETNA [100010801],,,76.8,,4960.8,9.170825,27238.33344,percent of total billed charges,
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,AETNA [1000108],AETNA [100010801],,,76.8,,13743.64,9.170825,27238.33344,percent of total billed charges,
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,AETNA [1000108],AETNA [100010801],,,76.8,,11703.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,AETNA [1000108],AETNA [100010801],,,76.8,,2438.18,9.170825,27238.33344,percent of total billed charges,
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,AETNA [1000108],AETNA [100010801],,,76.8,,3523.4,9.170825,27238.33344,percent of total billed charges,
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,AETNA [1000108],AETNA [100010801],,,76.8,,2919.14,9.170825,27238.33344,percent of total billed charges,
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,AETNA [1000108],AETNA [100010801],,,76.8,,7420.93,9.170825,27238.33344,percent of total billed charges,
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,AETNA [1000108],AETNA [100010801],,,76.8,,23226.16,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,AETNA [1000108],AETNA [100010801],,,76.8,,23226.16,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,AETNA [1000108],AETNA [100010801],,,76.8,,15255.97,9.170825,27238.33344,percent of total billed charges,
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA [1000108],AETNA [100010801],,,76.8,,10356.96,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA [1000108],AETNA [100010801],,,76.8,,10356.96,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA [1000108],AETNA [100010801],,,76.8,,10356.96,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA [1000108],AETNA [100010801],,,76.8,,10356.96,9.170825,27238.33344,percent of total billed charges,
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,AETNA [1000108],AETNA [100010801],,,76.8,,26841.96,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,AETNA [1000108],AETNA [100010801],,,76.8,,4494.7,9.170825,27238.33344,percent of total billed charges,
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,AETNA [1000108],AETNA [100010801],,,76.8,,4494.7,9.170825,27238.33344,percent of total billed charges,
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,AETNA [1000108],AETNA [100010801],,,76.8,,7106.49,9.170825,27238.33344,percent of total billed charges,
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,AETNA [1000108],AETNA [100010801],,,76.8,,4005.8,9.170825,27238.33344,percent of total billed charges,
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA [1000108],AETNA [100010801],,,76.8,,16907.04,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA [1000108],AETNA [100010801],,,76.8,,16907.04,9.170825,27238.33344,percent of total billed charges,
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,9.170825,27238.33344,percent of total billed charges,
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,9.170825,27238.33344,percent of total billed charges,
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,AETNA [1000108],AETNA [100010801],,,76.8,,3599.52,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,AETNA [1000108],AETNA [100010801],,,76.8,,6883.84,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,AETNA [1000108],AETNA [100010801],,,76.8,,5997.28,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA [1000108],AETNA [100010801],,,76.8,,4970.57,9.170825,27238.33344,percent of total billed charges,
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA [1000108],AETNA [100010801],,,76.8,,3079.8,9.170825,27238.33344,percent of total billed charges,
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA [1000108],AETNA [100010801],,,76.8,,3501.44,9.170825,27238.33344,percent of total billed charges,
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA [1000108],AETNA [100010801],,,76.8,,3501.44,9.170825,27238.33344,percent of total billed charges,
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,AETNA [1000108],AETNA [100010801],,,76.8,,184.63,9.170825,27238.33344,percent of total billed charges,
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,AETNA [1000108],AETNA [100010801],,,76.8,,211.07,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,AETNA [1000108],AETNA [100010801],,,76.8,,3446.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,9.170825,27238.33344,percent of total billed charges,
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,9.170825,27238.33344,percent of total billed charges,
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA [1000108],AETNA [100010801],,,76.8,,7473.78,9.170825,27238.33344,percent of total billed charges,
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA [1000108],AETNA [100010801],,,76.8,,7473.78,9.170825,27238.33344,percent of total billed charges,
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA [1000108],AETNA [100010801],,,76.8,,7473.78,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,AETNA [1000108],AETNA [100010801],,,76.8,,26091.99,9.170825,27238.33344,percent of total billed charges,
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,AETNA [1000108],AETNA [100010801],,,76.8,,24381.04,9.170825,27238.33344,percent of total billed charges,
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,9.170825,27238.33344,percent of total billed charges,
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA [1000108],AETNA [100010801],,,76.8,,4155.72,9.170825,27238.33344,percent of total billed charges,
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,AETNA [1000108],AETNA [100010801],,,76.8,,8725.85,9.170825,27238.33344,percent of total billed charges,
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,AETNA [1000108],AETNA [100010801],,,76.8,,8725.85,9.170825,27238.33344,percent of total billed charges,
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,AETNA [1000108],AETNA [100010801],,,76.8,,4302.4,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,AETNA [1000108],AETNA [100010801],,,76.8,,6297.15,9.170825,27238.33344,percent of total billed charges,
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,AETNA [1000108],AETNA [100010801],,,76.8,,8896.94,9.170825,27238.33344,percent of total billed charges,
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,AETNA [1000108],AETNA [100010801],,,76.8,,4201.49,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA [1000108],AETNA [100010801],,,76.8,,3993.57,9.170825,27238.33344,percent of total billed charges,
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,AETNA [1000108],AETNA [100010801],,,76.8,,1256.86,9.170825,27238.33344,percent of total billed charges,
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,AETNA [1000108],AETNA [100010801],,,76.8,,1097.07,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,AETNA [1000108],AETNA [100010801],,,76.8,,4999.91,9.170825,27238.33344,percent of total billed charges,
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,AETNA [1000108],AETNA [100010801],,,76.8,,4999.91,9.170825,27238.33344,percent of total billed charges,
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,AETNA [1000108],AETNA [100010801],,,76.8,,6143.95,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA [1000108],AETNA [100010801],,,76.8,,9610.89,9.170825,27238.33344,percent of total billed charges,
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA [1000108],AETNA [100010801],,,76.8,,9610.89,9.170825,27238.33344,percent of total billed charges,
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA [1000108],AETNA [100010801],,,76.8,,9610.89,9.170825,27238.33344,percent of total billed charges,
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA [1000108],AETNA [100010801],,,76.8,,3501.44,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,AETNA [1000108],AETNA [100010801],,,76.8,,14615.26,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,AETNA [1000108],AETNA [100010801],,,76.8,,3705.28,9.170825,27238.33344,percent of total billed charges,
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA [1000108],AETNA [100010801],,,76.8,,4970.57,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,AETNA [1000108],AETNA [100010801],,,76.8,,25393.36,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA [1000108],AETNA [100010801],,,76.8,,4970.57,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,AETNA [1000108],AETNA [100010801],,,76.8,,3518.81,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,AETNA [1000108],AETNA [100010801],,,76.8,,3518.81,9.170825,27238.33344,percent of total billed charges,
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA [1000108],AETNA [100010801],,,76.8,,10368.13,9.170825,27238.33344,percent of total billed charges,
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA [1000108],AETNA [100010801],,,76.8,,10368.13,9.170825,27238.33344,percent of total billed charges,
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA [1000108],AETNA [100010801],,,76.8,,10368.13,9.170825,27238.33344,percent of total billed charges,
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,AETNA [1000108],AETNA [100010801],,,76.8,,11807.55,9.170825,27238.33344,percent of total billed charges,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA [1000108],AETNA [100010801],,,76.8,,11808.41,9.170825,27238.33344,percent of total billed charges,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA [1000108],AETNA [100010801],,,76.8,,11808.41,9.170825,27238.33344,percent of total billed charges,
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA [1000108],AETNA [100010801],,,76.8,,11808.41,9.170825,27238.33344,percent of total billed charges,
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,AETNA [1000108],AETNA [100010801],,,76.8,,10416.84,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,AETNA [1000108],AETNA [100010801],,,76.8,,3678.13,9.170825,27238.33344,percent of total billed charges,
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,AETNA [1000108],AETNA [100010801],,,76.8,,3678.13,9.170825,27238.33344,percent of total billed charges,
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,AETNA [1000108],AETNA [100010801],,,76.8,,24697.57,9.170825,27238.33344,percent of total billed charges,
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,AETNA [1000108],AETNA [100010801],,,76.8,,23931.4,9.170825,27238.33344,percent of total billed charges,
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,AETNA [1000108],AETNA [100010801],,,76.8,,25932.3,9.170825,27238.33344,percent of total billed charges,
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,AETNA [1000108],AETNA [100010801],,,76.8,,13031.74,9.170825,27238.33344,percent of total billed charges,
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA [1000108],AETNA [100010801],,,76.8,,3339.57,9.170825,27238.33344,percent of total billed charges,
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA [1000108],AETNA [100010801],,,76.8,,3339.57,9.170825,27238.33344,percent of total billed charges,
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA [1000108],AETNA [100010801],,,76.8,,3339.57,9.170825,27238.33344,percent of total billed charges,
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,AETNA [1000108],AETNA [100010801],,,76.8,,3465.4,9.170825,27238.33344,percent of total billed charges,
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,AETNA [1000108],AETNA [100010801],,,76.8,,10422.54,9.170825,27238.33344,percent of total billed charges,
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,AETNA [1000108],AETNA [100010801],,,76.8,,14343.47,9.170825,27238.33344,percent of total billed charges,
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,AETNA [1000108],AETNA [100010801],,,76.8,,13031.74,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,AETNA [1000108],AETNA [100010801],,,76.8,,7243.02,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA [1000108],AETNA [100010801],,,76.8,,9758.12,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA [1000108],AETNA [100010801],,,76.8,,9758.12,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA [1000108],AETNA [100010801],,,76.8,,9758.12,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,AETNA [1000108],AETNA [100010801],,,76.8,,9387.42,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,AETNA [1000108],AETNA [100010801],,,76.8,,11603.1,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA [1000108],AETNA [100010801],,,76.8,,4155.72,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,AETNA [1000108],AETNA [100010801],,,76.8,,21010.6,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,9.170825,27238.33344,percent of total billed charges,
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,9.170825,27238.33344,percent of total billed charges,
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA [1000108],AETNA [100010801],,,76.8,,3441.91,9.170825,27238.33344,percent of total billed charges,
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA [1000108],AETNA [100010801],,,76.8,,3441.91,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,9.170825,27238.33344,percent of total billed charges,
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,AETNA [1000108],AETNA [100010801],,,76.8,,3375.17,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,AETNA [1000108],AETNA [100010801],,,76.8,,3375.17,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,AETNA [1000108],AETNA [100010801],,,76.8,,13449.35,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,9.170825,27238.33344,percent of total billed charges,
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,AETNA [1000108],AETNA [100010801],,,76.8,,7672.61,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA [1000108],AETNA [100010801],,,76.8,,461.75,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA [1000108],AETNA [100010801],,,76.8,,461.75,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA [1000108],AETNA [100010801],,,76.8,,461.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,AETNA [1000108],AETNA [100010801],,,76.8,,8100.43,9.170825,27238.33344,percent of total billed charges,
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA [1000108],AETNA [100010801],,,76.8,,8998.4,9.170825,27238.33344,percent of total billed charges,
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA [1000108],AETNA [100010801],,,76.8,,8998.4,9.170825,27238.33344,percent of total billed charges,
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA [1000108],AETNA [100010801],,,76.8,,8998.4,9.170825,27238.33344,percent of total billed charges,
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,AETNA [1000108],AETNA [100010801],,,76.8,,18914.56,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,AETNA [1000108],AETNA [100010801],,,76.8,,3088.01,9.170825,27238.33344,percent of total billed charges,
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,AETNA [1000108],AETNA [100010801],,,76.8,,4040.02,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,AETNA [1000108],AETNA [100010801],,,76.8,,3423.83,9.170825,27238.33344,percent of total billed charges,
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,AETNA [1000108],AETNA [100010801],,,76.8,,3423.83,9.170825,27238.33344,percent of total billed charges,
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA [1000108],AETNA [100010801],,,76.8,,3132.82,9.170825,27238.33344,percent of total billed charges,
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA [1000108],AETNA [100010801],,,76.8,,3132.82,9.170825,27238.33344,percent of total billed charges,
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA [1000108],AETNA [100010801],,,76.8,,3132.82,9.170825,27238.33344,percent of total billed charges,
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,AETNA [1000108],AETNA [100010801],,,76.8,,10860,9.170825,27238.33344,percent of total billed charges,
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,AETNA [1000108],AETNA [100010801],,,76.8,,10860,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,AETNA [1000108],AETNA [100010801],,,76.8,,2760.61,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA [1000108],AETNA [100010801],,,76.8,,15765.47,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA [1000108],AETNA [100010801],,,76.8,,15765.47,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA [1000108],AETNA [100010801],,,76.8,,15765.47,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA [1000108],AETNA [100010801],,,76.8,,15765.47,9.170825,27238.33344,percent of total billed charges,
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,AETNA [1000108],AETNA [100010801],,,76.8,,2640.93,9.170825,27238.33344,percent of total billed charges,
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,AETNA [1000108],AETNA [100010801],,,76.8,,8643.55,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,AETNA [1000108],AETNA [100010801],,,76.8,,8643.55,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,AETNA [1000108],AETNA [100010801],,,76.8,,1250.66,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,AETNA [1000108],AETNA [100010801],,,76.8,,3420.99,9.170825,27238.33344,percent of total billed charges,
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,AETNA [1000108],AETNA [100010801],,,76.8,,2308.57,9.170825,27238.33344,percent of total billed charges,
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,AETNA [1000108],AETNA [100010801],,,76.8,,2308.57,9.170825,27238.33344,percent of total billed charges,
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,AETNA [1000108],AETNA [100010801],,,76.8,,1931.29,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA [1000108],AETNA [100010801],,,76.8,,9656.58,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA [1000108],AETNA [100010801],,,76.8,,9656.58,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA [1000108],AETNA [100010801],,,76.8,,9656.58,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,AETNA [1000108],AETNA [100010801],,,76.8,,3849.02,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,AETNA [1000108],AETNA [100010801],,,76.8,,3849.02,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,AETNA [1000108],AETNA [100010801],,,76.8,,11440.9,9.170825,27238.33344,percent of total billed charges,
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,AETNA [1000108],AETNA [100010801],,,76.8,,11440.9,9.170825,27238.33344,percent of total billed charges,
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,AETNA [1000108],AETNA [100010801],,,76.8,,14602.94,9.170825,27238.33344,percent of total billed charges,
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,AETNA [1000108],AETNA [100010801],,,76.8,,21040.18,9.170825,27238.33344,percent of total billed charges,
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,AETNA [1000108],AETNA [100010801],,,76.8,,21040.18,9.170825,27238.33344,percent of total billed charges,
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,AETNA [1000108],AETNA [100010801],,,76.8,,20852.95,9.170825,27238.33344,percent of total billed charges,
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,AETNA [1000108],AETNA [100010801],,,76.8,,20852.95,9.170825,27238.33344,percent of total billed charges,
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,AETNA [1000108],AETNA [100010801],,,76.8,,1284.58,9.170825,27238.33344,percent of total billed charges,
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,AETNA [1000108],AETNA [100010801],,,76.8,,3427.38,9.170825,27238.33344,percent of total billed charges,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,AETNA [1000108],AETNA [100010801],,,76.8,,20999.66,9.170825,27238.33344,percent of total billed charges,
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,AETNA [1000108],AETNA [100010801],,,76.8,,20999.66,9.170825,27238.33344,percent of total billed charges,
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,AETNA [1000108],AETNA [100010801],,,76.8,,8632.37,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,AETNA [1000108],AETNA [100010801],,,76.8,,7819.33,9.170825,27238.33344,percent of total billed charges,
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,9.170825,27238.33344,percent of total billed charges,
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,AETNA [1000108],AETNA [100010801],,,76.8,,1632.18,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,AETNA [1000108],AETNA [100010801],,,76.8,,4036.59,9.170825,27238.33344,percent of total billed charges,
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,AETNA [1000108],AETNA [100010801],,,76.8,,4036.59,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,9.170825,27238.33344,percent of total billed charges,
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,AETNA [1000108],AETNA [100010801],,,76.8,,2765.78,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,AETNA [1000108],AETNA [100010801],,,76.8,,2765.78,9.170825,27238.33344,percent of total billed charges,
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA [1000108],AETNA [100010801],,,76.8,,6510.64,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA [1000108],AETNA [100010801],,,76.8,,6510.64,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA [1000108],AETNA [100010801],,,76.8,,6510.64,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA [1000108],AETNA [100010801],,,76.8,,6510.64,9.170825,27238.33344,percent of total billed charges,
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,9.170825,27238.33344,percent of total billed charges,
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA [1000108],AETNA [100010801],,,76.8,,3215.53,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA [1000108],AETNA [100010801],,,76.8,,3215.53,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA [1000108],AETNA [100010801],,,76.8,,3215.53,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA [1000108],AETNA [100010801],,,76.8,,3915.57,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA [1000108],AETNA [100010801],,,76.8,,3915.57,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA [1000108],AETNA [100010801],,,76.8,,3915.57,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA [1000108],AETNA [100010801],,,76.8,,3915.57,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA [1000108],AETNA [100010801],,,76.8,,7525.47,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA [1000108],AETNA [100010801],,,76.8,,7525.47,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA [1000108],AETNA [100010801],,,76.8,,7525.47,9.170825,27238.33344,percent of total billed charges,
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA [1000108],AETNA [100010801],,,76.8,,7525.47,9.170825,27238.33344,percent of total billed charges,
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,AETNA [1000108],AETNA [100010801],,,76.8,,7701.04,9.170825,27238.33344,percent of total billed charges,
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,AETNA [1000108],AETNA [100010801],,,76.8,,7701.04,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,AETNA [1000108],AETNA [100010801],,,76.8,,622.54,9.170825,27238.33344,percent of total billed charges,
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,AETNA [1000108],AETNA [100010801],,,76.8,,2116.23,9.170825,27238.33344,percent of total billed charges,
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,AETNA [1000108],AETNA [100010801],,,76.8,,6984.88,9.170825,27238.33344,percent of total billed charges,
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,AETNA [1000108],AETNA [100010801],,,76.8,,4784.79,9.170825,27238.33344,percent of total billed charges,
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,AETNA [1000108],AETNA [100010801],,,76.8,,313.2,9.170825,27238.33344,percent of total billed charges,
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,AETNA [1000108],AETNA [100010801],,,76.8,,6707.83,9.170825,27238.33344,percent of total billed charges,
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,AETNA [1000108],AETNA [100010801],,,76.8,,5384.52,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,AETNA [1000108],AETNA [100010801],,,76.8,,6404.71,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,AETNA [1000108],AETNA [100010801],,,76.8,,3291.99,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,9.170825,27238.33344,percent of total billed charges,
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,AETNA [1000108],AETNA [100010801],,,76.8,,1922.13,9.170825,27238.33344,percent of total billed charges,
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,AETNA [1000108],AETNA [100010801],,,76.8,,5263.92,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,AETNA [1000108],AETNA [100010801],,,76.8,,22784.16,9.170825,27238.33344,percent of total billed charges,
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,AETNA [1000108],AETNA [100010801],,,76.8,,8055.73,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,AETNA [1000108],AETNA [100010801],,,76.8,,7598.48,9.170825,27238.33344,percent of total billed charges,
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,AETNA [1000108],AETNA [100010801],,,76.8,,7353.19,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,AETNA [1000108],AETNA [100010801],,,76.8,,2718.41,9.170825,27238.33344,percent of total billed charges,
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,AETNA [1000108],AETNA [100010801],,,76.8,,4589.22,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.170825,27238.33344,percent of total billed charges,
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,AETNA [1000108],AETNA [100010801],,,76.8,,4660.93,9.170825,27238.33344,percent of total billed charges,
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,AETNA [1000108],AETNA [100010801],,,76.8,,6828.43,9.170825,27238.33344,percent of total billed charges,
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,9.170825,27238.33344,percent of total billed charges,
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,9.170825,27238.33344,percent of total billed charges,
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,9.170825,27238.33344,percent of total billed charges,
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,AETNA [1000108],AETNA [100010801],,,76.8,,6525.3,9.170825,27238.33344,percent of total billed charges,
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,AETNA [1000108],AETNA [100010801],,,76.8,,6525.3,9.170825,27238.33344,percent of total billed charges,
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,AETNA [1000108],AETNA [100010801],,,76.8,,9110.81,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA [1000108],AETNA [100010801],,,76.8,,4595.74,9.170825,27238.33344,percent of total billed charges,
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA [1000108],AETNA [100010801],,,76.8,,4595.74,9.170825,27238.33344,percent of total billed charges,
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA [1000108],AETNA [100010801],,,76.8,,4595.74,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,AETNA [1000108],AETNA [100010801],,,76.8,,5012.94,9.170825,27238.33344,percent of total billed charges,
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,AETNA [1000108],AETNA [100010801],,,76.8,,4709.82,9.170825,27238.33344,percent of total billed charges,
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,AETNA [1000108],AETNA [100010801],,,76.8,,4709.82,9.170825,27238.33344,percent of total billed charges,
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,AETNA [1000108],AETNA [100010801],,,76.8,,3308.94,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA [1000108],AETNA [100010801],,,76.8,,10836.02,9.170825,27238.33344,percent of total billed charges,
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,AETNA [1000108],AETNA [100010801],,,76.8,,9680.56,9.170825,27238.33344,percent of total billed charges,
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA [1000108],AETNA [100010801],,,76.8,,10836.02,9.170825,27238.33344,percent of total billed charges,
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA [1000108],AETNA [100010801],,,76.8,,10836.02,9.170825,27238.33344,percent of total billed charges,
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,9.170825,27238.33344,percent of total billed charges,
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,AETNA [1000108],AETNA [100010801],,,76.8,,10893.5,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,9.170825,27238.33344,percent of total billed charges,
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,AETNA [1000108],AETNA [100010801],,,76.8,,2585.56,9.170825,27238.33344,percent of total billed charges,
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,AETNA [1000108],AETNA [100010801],,,76.8,,9110.81,9.170825,27238.33344,percent of total billed charges,
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,9.170825,27238.33344,percent of total billed charges,
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA [1000108],AETNA [100010801],,,76.8,,16289.67,9.170825,27238.33344,percent of total billed charges,
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA [1000108],AETNA [100010801],,,76.8,,16289.67,9.170825,27238.33344,percent of total billed charges,
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,AETNA [1000108],AETNA [100010801],,,76.8,,17608.54,9.170825,27238.33344,percent of total billed charges,
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA [1000108],AETNA [100010801],,,76.8,,16289.67,9.170825,27238.33344,percent of total billed charges,
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA [1000108],AETNA [100010801],,,76.8,,17145.15,9.170825,27238.33344,percent of total billed charges,
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA [1000108],AETNA [100010801],,,76.8,,17145.15,9.170825,27238.33344,percent of total billed charges,
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA [1000108],AETNA [100010801],,,76.8,,17145.15,9.170825,27238.33344,percent of total billed charges,
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,AETNA [1000108],AETNA [100010801],,,76.8,,18007.76,9.170825,27238.33344,percent of total billed charges,
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,AETNA [1000108],AETNA [100010801],,,76.8,,4615.3,9.170825,27238.33344,percent of total billed charges,
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,AETNA [1000108],AETNA [100010801],,,76.8,,4476.25,9.170825,27238.33344,percent of total billed charges,
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,AETNA [1000108],AETNA [100010801],,,76.8,,98.59,9.170825,27238.33344,percent of total billed charges,
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,76.8,,94.11,9.170825,27238.33344,percent of total billed charges,
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,AETNA [1000108],AETNA [100010801],,,76.8,,3239.66,9.170825,27238.33344,percent of total billed charges,
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,AETNA [1000108],AETNA [100010801],,,76.8,,1549.75,9.170825,27238.33344,percent of total billed charges,
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,AETNA [1000108],AETNA [100010801],,,76.8,,3439.11,9.170825,27238.33344,percent of total billed charges,
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,AETNA [1000108],AETNA [100010801],,,76.8,,3306.86,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,AETNA [1000108],AETNA [100010801],,,76.8,,3306.86,9.170825,27238.33344,percent of total billed charges,
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,9.170825,27238.33344,percent of total billed charges,
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,AETNA [1000108],AETNA [100010801],,,76.8,,13602.14,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA [1000108],AETNA [100010801],,,76.8,,5575.19,9.170825,27238.33344,percent of total billed charges,
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,76.8,,677.57,9.170825,27238.33344,percent of total billed charges,
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,AETNA [1000108],AETNA [100010801],,,76.8,,6942.5,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,AETNA [1000108],AETNA [100010801],,,76.8,,9102.26,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,AETNA [1000108],AETNA [100010801],,,76.8,,8050.02,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,AETNA [1000108],AETNA [100010801],,,76.8,,5528.94,9.170825,27238.33344,percent of total billed charges,
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,AETNA [1000108],AETNA [100010801],,,76.8,,6616.73,9.170825,27238.33344,percent of total billed charges,
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,AETNA [1000108],AETNA [100010801],,,76.8,,1247.09,9.170825,27238.33344,percent of total billed charges,
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,AETNA [1000108],AETNA [100010801],,,76.8,,5103.75,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,AETNA [1000108],AETNA [100010801],,,76.8,,9645.48,9.170825,27238.33344,percent of total billed charges,
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,AETNA [1000108],AETNA [100010801],,,76.8,,9645.48,9.170825,27238.33344,percent of total billed charges,
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA [1000108],AETNA [100010801],,,76.8,,16593.17,9.170825,27238.33344,percent of total billed charges,
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA [1000108],AETNA [100010801],,,76.8,,16593.17,9.170825,27238.33344,percent of total billed charges,
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA [1000108],AETNA [100010801],,,76.8,,16593.17,9.170825,27238.33344,percent of total billed charges,
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,AETNA [1000108],AETNA [100010801],,,76.8,,15862.45,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,AETNA [1000108],AETNA [100010801],,,76.8,,14831.09,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,AETNA [1000108],AETNA [100010801],,,76.8,,785.12,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,9.170825,27238.33344,percent of total billed charges,
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA [1000108],AETNA [100010801],,,76.8,,7529.2,9.170825,27238.33344,percent of total billed charges,
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA [1000108],AETNA [100010801],,,76.8,,7529.2,9.170825,27238.33344,percent of total billed charges,
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA [1000108],AETNA [100010801],,,76.8,,7529.2,9.170825,27238.33344,percent of total billed charges,
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,9.170825,27238.33344,percent of total billed charges,
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,9.170825,27238.33344,percent of total billed charges,
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,AETNA [1000108],AETNA [100010801],,,76.8,,4726.61,9.170825,27238.33344,percent of total billed charges,
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,AETNA [1000108],AETNA [100010801],,,76.8,,31.37,9.170825,27238.33344,percent of total billed charges,
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,AETNA [1000108],AETNA [100010801],,,76.8,,10479.58,9.170825,27238.33344,percent of total billed charges,
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,AETNA [1000108],AETNA [100010801],,,76.8,,10479.58,9.170825,27238.33344,percent of total billed charges,
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,AETNA [1000108],AETNA [100010801],,,76.8,,5589.86,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,9.170825,27238.33344,percent of total billed charges,
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,9.170825,27238.33344,percent of total billed charges,
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,9.170825,27238.33344,percent of total billed charges,
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,9.170825,27238.33344,percent of total billed charges,
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,9.170825,27238.33344,percent of total billed charges,
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,AETNA [1000108],AETNA [100010801],,,76.8,,5250.49,9.170825,27238.33344,percent of total billed charges,
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,AETNA [1000108],AETNA [100010801],,,76.8,,7627.99,9.170825,27238.33344,percent of total billed charges,
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,AETNA [1000108],AETNA [100010801],,,76.8,,6857.76,9.170825,27238.33344,percent of total billed charges,
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,AETNA [1000108],AETNA [100010801],,,76.8,,18603.73,9.170825,27238.33344,percent of total billed charges,
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,AETNA [1000108],AETNA [100010801],,,76.8,,11657.27,9.170825,27238.33344,percent of total billed charges,
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,AETNA [1000108],AETNA [100010801],,,76.8,,5311.37,9.170825,27238.33344,percent of total billed charges,
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA [1000108],AETNA [100010801],,,76.8,,7528.18,9.170825,27238.33344,percent of total billed charges,
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA [1000108],AETNA [100010801],,,76.8,,3079.8,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA [1000108],AETNA [100010801],,,76.8,,7528.18,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA [1000108],AETNA [100010801],,,76.8,,7528.18,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA [1000108],AETNA [100010801],,,76.8,,3079.8,9.170825,27238.33344,percent of total billed charges,
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,AETNA [1000108],AETNA [100010801],,,76.8,,4517.51,9.170825,27238.33344,percent of total billed charges,
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,AETNA [1000108],AETNA [100010801],,,76.8,,7904.59,9.170825,27238.33344,percent of total billed charges,
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA [1000108],AETNA [100010801],,,76.8,,917.96,9.170825,27238.33344,percent of total billed charges,
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,AETNA [1000108],AETNA [100010801],,,76.8,,16370.94,9.170825,27238.33344,percent of total billed charges,
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,AETNA [1000108],AETNA [100010801],,,76.8,,8162.17,9.170825,27238.33344,percent of total billed charges,
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,AETNA [1000108],AETNA [100010801],,,76.8,,8162.17,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,AETNA [1000108],AETNA [100010801],,,76.8,,5369.1,9.170825,27238.33344,percent of total billed charges,
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,AETNA [1000108],AETNA [100010801],,,76.8,,4621.82,9.170825,27238.33344,percent of total billed charges,
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA [1000108],AETNA [100010801],,,76.8,,3308.28,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,AETNA [1000108],AETNA [100010801],,,76.8,,3960.16,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,9.170825,27238.33344,percent of total billed charges,
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA [1000108],AETNA [100010801],,,76.8,,8058.19,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA [1000108],AETNA [100010801],,,76.8,,8058.19,9.170825,27238.33344,percent of total billed charges,
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA [1000108],AETNA [100010801],,,76.8,,8058.19,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,9.170825,27238.33344,percent of total billed charges,
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,9.170825,27238.33344,percent of total billed charges,
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,AETNA [1000108],AETNA [100010801],,,76.8,,6215.66,9.170825,27238.33344,percent of total billed charges,
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,9.170825,27238.33344,percent of total billed charges,
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,AETNA [1000108],AETNA [100010801],,,76.8,,7031.49,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,AETNA [1000108],AETNA [100010801],,,76.8,,9780.93,9.170825,27238.33344,percent of total billed charges,
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,AETNA [1000108],AETNA [100010801],,,76.8,,9495.77,9.170825,27238.33344,percent of total billed charges,
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,AETNA [1000108],AETNA [100010801],,,76.8,,8526.24,9.170825,27238.33344,percent of total billed charges,
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,9.170825,27238.33344,percent of total billed charges,
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,9.170825,27238.33344,percent of total billed charges,
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,AETNA [1000108],AETNA [100010801],,,76.8,,4922.33,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,AETNA [1000108],AETNA [100010801],,,76.8,,5589.86,9.170825,27238.33344,percent of total billed charges,
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,AETNA [1000108],AETNA [100010801],,,76.8,,5818.01,9.170825,27238.33344,percent of total billed charges,
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA [1000108],AETNA [100010801],,,76.8,,3308.28,9.170825,27238.33344,percent of total billed charges,
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,AETNA [1000108],AETNA [100010801],,,76.8,,8403.33,9.170825,27238.33344,percent of total billed charges,
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,AETNA [1000108],AETNA [100010801],,,76.8,,8403.33,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,AETNA [1000108],AETNA [100010801],,,76.8,,8099.59,9.170825,27238.33344,percent of total billed charges,
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,AETNA [1000108],AETNA [100010801],,,76.8,,2126.53,9.170825,27238.33344,percent of total billed charges,
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,9.170825,27238.33344,percent of total billed charges,
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA [1000108],AETNA [100010801],,,76.8,,18535.3,9.170825,27238.33344,percent of total billed charges,
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA [1000108],AETNA [100010801],,,76.8,,18535.3,9.170825,27238.33344,percent of total billed charges,
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA [1000108],AETNA [100010801],,,76.8,,18535.3,9.170825,27238.33344,percent of total billed charges,
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,9966.28992,percent of total billed charges,
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,9966.28992,percent of total billed charges,
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,9966.28992,percent of total billed charges,
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,AETNA [1000108],AETNA [100010801],,,76.8,,9966.29,399.86,9966.28992,percent of total billed charges,
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,9966.28992,percent of total billed charges,
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,9966.28992,percent of total billed charges,
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,9966.28992,percent of total billed charges,
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,AETNA [1000108],AETNA [100010801],,,76.8,,8243.93,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,399.86,9966.28992,percent of total billed charges,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,399.86,9966.28992,percent of total billed charges,
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,150.646235,34103.808,percent of total billed charges,
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,150.646235,34103.808,percent of total billed charges,
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,150.646235,34103.808,percent of total billed charges,
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,AETNA [1000108],AETNA [100010801],,,76.8,,11121.18,150.646235,34103.808,percent of total billed charges,
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,150.646235,34103.808,percent of total billed charges,
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,150.646235,34103.808,percent of total billed charges,
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA [1000108],AETNA [100010801],,,76.8,,2309.85,150.646235,34103.808,percent of total billed charges,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,76.8,,5524.67,150.646235,34103.808,percent of total billed charges,
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,76.8,,5524.67,150.646235,34103.808,percent of total billed charges,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,76.8,,5524.67,150.646235,34103.808,percent of total billed charges,
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,AETNA [1000108],AETNA [100010801],,,76.8,,3454.96,150.646235,34103.808,percent of total billed charges,
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,AETNA [1000108],AETNA [100010801],,,76.8,,13687.6,150.646235,34103.808,percent of total billed charges,
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,AETNA [1000108],AETNA [100010801],,,76.8,,13687.6,150.646235,34103.808,percent of total billed charges,
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,AETNA [1000108],AETNA [100010801],,,76.8,,8546.2,150.646235,34103.808,percent of total billed charges,
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,150.646235,34103.808,percent of total billed charges,
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,AETNA [1000108],AETNA [100010801],,,76.8,,23097.83,150.646235,34103.808,percent of total billed charges,
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA [1000108],AETNA [100010801],,,76.8,,6411.23,150.646235,34103.808,percent of total billed charges,
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA [1000108],AETNA [100010801],,,76.8,,6411.23,150.646235,34103.808,percent of total billed charges,
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA [1000108],AETNA [100010801],,,76.8,,15883.32,150.646235,34103.808,percent of total billed charges,
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA [1000108],AETNA [100010801],,,76.8,,15883.32,150.646235,34103.808,percent of total billed charges,
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA [1000108],AETNA [100010801],,,76.8,,15883.32,150.646235,34103.808,percent of total billed charges,
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,150.646235,34103.808,percent of total billed charges,
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,150.646235,34103.808,percent of total billed charges,
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,150.646235,34103.808,percent of total billed charges,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,150.646235,34103.808,percent of total billed charges,
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,150.646235,34103.808,percent of total billed charges,
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,AETNA [1000108],AETNA [100010801],,,76.8,,4758.71,150.646235,34103.808,percent of total billed charges,
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA [1000108],AETNA [100010801],,,76.8,,6411.23,150.646235,34103.808,percent of total billed charges,
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,AETNA [1000108],AETNA [100010801],,,76.8,,7166.26,150.646235,34103.808,percent of total billed charges,
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,AETNA [1000108],AETNA [100010801],,,76.8,,7303.19,150.646235,34103.808,percent of total billed charges,
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,AETNA [1000108],AETNA [100010801],,,76.8,,1975.66,150.646235,34103.808,percent of total billed charges,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,AETNA [1000108],AETNA [100010801],,,76.8,,31261.82,150.646235,34103.808,percent of total billed charges,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,AETNA [1000108],AETNA [100010801],,,76.8,,34103.81,150.646235,34103.808,percent of total billed charges,
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,AETNA [1000108],AETNA [100010801],,,76.8,,22812.67,150.646235,34103.808,percent of total billed charges,
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,150.646235,34103.808,percent of total billed charges,
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,399.86,2035.392,percent of total billed charges,
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,399.86,2035.392,percent of total billed charges,
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,399.86,2035.392,percent of total billed charges,
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,399.86,2035.392,percent of total billed charges,
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,399.86,2035.392,percent of total billed charges,
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,AETNA [1000108],AETNA [100010801],,,76.8,,3862.44,26.19915,15398.5536,percent of total billed charges,
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,AETNA [1000108],AETNA [100010801],,,76.8,,2932.78,26.19915,15398.5536,percent of total billed charges,
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,AETNA [1000108],AETNA [100010801],,,76.8,,5470.89,26.19915,15398.5536,percent of total billed charges,
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,AETNA [1000108],AETNA [100010801],,,76.8,,3333.15,26.19915,15398.5536,percent of total billed charges,
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,AETNA [1000108],AETNA [100010801],,,76.8,,3849.99,26.19915,15398.5536,percent of total billed charges,
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,AETNA [1000108],AETNA [100010801],,,76.8,,3200.79,26.19915,15398.5536,percent of total billed charges,
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,AETNA [1000108],AETNA [100010801],,,76.8,,755.79,26.19915,15398.5536,percent of total billed charges,
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,AETNA [1000108],AETNA [100010801],,,76.8,,1274.97,26.19915,15398.5536,percent of total billed charges,
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,AETNA [1000108],AETNA [100010801],,,76.8,,890.41,26.19915,15398.5536,percent of total billed charges,
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,76.8,,822.99,26.19915,15398.5536,percent of total billed charges,
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,AETNA [1000108],AETNA [100010801],,,76.8,,912.31,26.19915,15398.5536,percent of total billed charges,
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,76.8,,822.99,26.19915,15398.5536,percent of total billed charges,
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,AETNA [1000108],AETNA [100010801],,,76.8,,912.31,26.19915,15398.5536,percent of total billed charges,
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,76.8,,1119.47,26.19915,15398.5536,percent of total billed charges,
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,AETNA [1000108],AETNA [100010801],,,76.8,,2269.16,26.19915,15398.5536,percent of total billed charges,
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,26.19915,15398.5536,percent of total billed charges,
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,AETNA [1000108],AETNA [100010801],,,76.8,,98.59,26.19915,15398.5536,percent of total billed charges,
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA [1000108],AETNA [100010801],,,76.8,,125.48,26.19915,15398.5536,percent of total billed charges,
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA [1000108],AETNA [100010801],,,76.8,,125.48,26.19915,15398.5536,percent of total billed charges,
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,AETNA [1000108],AETNA [100010801],,,76.8,,367.46,26.19915,15398.5536,percent of total billed charges,
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,AETNA [1000108],AETNA [100010801],,,76.8,,147.89,26.19915,15398.5536,percent of total billed charges,
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,AETNA [1000108],AETNA [100010801],,,76.8,,14537.37,26.19915,15398.5536,percent of total billed charges,
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,AETNA [1000108],AETNA [100010801],,,76.8,,1347.43,26.19915,15398.5536,percent of total billed charges,
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,AETNA [1000108],AETNA [100010801],,,76.8,,3083.47,26.19915,15398.5536,percent of total billed charges,
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,26.19915,15398.5536,percent of total billed charges,
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,26.19915,15398.5536,percent of total billed charges,
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,AETNA [1000108],AETNA [100010801],,,76.8,,2610.52,26.19915,15398.5536,percent of total billed charges,
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,AETNA [1000108],AETNA [100010801],,,76.8,,2610.52,26.19915,15398.5536,percent of total billed charges,
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,AETNA [1000108],AETNA [100010801],,,76.8,,3394.01,26.19915,15398.5536,percent of total billed charges,
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,AETNA [1000108],AETNA [100010801],,,76.8,,1760.45,26.19915,15398.5536,percent of total billed charges,
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,AETNA [1000108],AETNA [100010801],,,76.8,,1911.38,26.19915,15398.5536,percent of total billed charges,
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,AETNA [1000108],AETNA [100010801],,,76.8,,2432.68,26.19915,15398.5536,percent of total billed charges,
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,AETNA [1000108],AETNA [100010801],,,76.8,,2892.08,26.19915,15398.5536,percent of total billed charges,
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,AETNA [1000108],AETNA [100010801],,,76.8,,3559,26.19915,15398.5536,percent of total billed charges,
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,AETNA [1000108],AETNA [100010801],,,76.8,,4706.57,26.19915,15398.5536,percent of total billed charges,
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,AETNA [1000108],AETNA [100010801],,,76.8,,9230.01,26.19915,15398.5536,percent of total billed charges,
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,AETNA [1000108],AETNA [100010801],,,76.8,,2857.62,26.19915,15398.5536,percent of total billed charges,
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,AETNA [1000108],AETNA [100010801],,,76.8,,2998.41,26.19915,15398.5536,percent of total billed charges,
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,AETNA [1000108],AETNA [100010801],,,76.8,,3575.55,26.19915,15398.5536,percent of total billed charges,
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,AETNA [1000108],AETNA [100010801],,,76.8,,357.34,26.19915,15398.5536,percent of total billed charges,
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,26.19915,15398.5536,percent of total billed charges,
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,26.19915,15398.5536,percent of total billed charges,
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,26.19915,15398.5536,percent of total billed charges,
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,26.19915,15398.5536,percent of total billed charges,
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,26.19915,15398.5536,percent of total billed charges,
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,26.19915,15398.5536,percent of total billed charges,
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,AETNA [1000108],AETNA [100010801],,,76.8,,891.5,26.19915,15398.5536,percent of total billed charges,
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,AETNA [1000108],AETNA [100010801],,,76.8,,1542.83,26.19915,15398.5536,percent of total billed charges,
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,15398.5536,percent of total billed charges,
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,AETNA [1000108],AETNA [100010801],,,76.8,,1278.39,26.19915,15398.5536,percent of total billed charges,
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,AETNA [1000108],AETNA [100010801],,,76.8,,1442.97,26.19915,15398.5536,percent of total billed charges,
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,AETNA [1000108],AETNA [100010801],,,76.8,,1442.97,26.19915,15398.5536,percent of total billed charges,
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,AETNA [1000108],AETNA [100010801],,,76.8,,1450.01,26.19915,15398.5536,percent of total billed charges,
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,AETNA [1000108],AETNA [100010801],,,76.8,,1611.99,26.19915,15398.5536,percent of total billed charges,
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,AETNA [1000108],AETNA [100010801],,,76.8,,1611.99,26.19915,15398.5536,percent of total billed charges,
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,AETNA [1000108],AETNA [100010801],,,76.8,,3210.98,26.19915,15398.5536,percent of total billed charges,
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,AETNA [1000108],AETNA [100010801],,,76.8,,3753.06,26.19915,15398.5536,percent of total billed charges,
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,AETNA [1000108],AETNA [100010801],,,76.8,,2255.37,26.19915,15398.5536,percent of total billed charges,
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,AETNA [1000108],AETNA [100010801],,,76.8,,1874.43,26.19915,15398.5536,percent of total billed charges,
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,AETNA [1000108],AETNA [100010801],,,76.8,,1474.93,26.19915,15398.5536,percent of total billed charges,
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,AETNA [1000108],AETNA [100010801],,,76.8,,1930.53,26.19915,15398.5536,percent of total billed charges,
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,AETNA [1000108],AETNA [100010801],,,76.8,,2601.52,26.19915,15398.5536,percent of total billed charges,
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,AETNA [1000108],AETNA [100010801],,,76.8,,2486.21,26.19915,15398.5536,percent of total billed charges,
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,AETNA [1000108],AETNA [100010801],,,76.8,,1430.39,26.19915,15398.5536,percent of total billed charges,
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,AETNA [1000108],AETNA [100010801],,,76.8,,1535.78,26.19915,15398.5536,percent of total billed charges,
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,AETNA [1000108],AETNA [100010801],,,76.8,,3936.5,26.19915,15398.5536,percent of total billed charges,
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,AETNA [1000108],AETNA [100010801],,,76.8,,1315.19,26.19915,15398.5536,percent of total billed charges,
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,AETNA [1000108],AETNA [100010801],,,76.8,,1576.08,26.19915,15398.5536,percent of total billed charges,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,AETNA [1000108],AETNA [100010801],,,76.8,,1634.7,26.19915,15398.5536,percent of total billed charges,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,AETNA [1000108],AETNA [100010801],,,76.8,,1816.59,26.19915,15398.5536,percent of total billed charges,
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,AETNA [1000108],AETNA [100010801],,,76.8,,2024.44,26.19915,15398.5536,percent of total billed charges,
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,AETNA [1000108],AETNA [100010801],,,76.8,,1980.72,26.19915,15398.5536,percent of total billed charges,
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,AETNA [1000108],AETNA [100010801],,,76.8,,1565.9,26.19915,15398.5536,percent of total billed charges,
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,AETNA [1000108],AETNA [100010801],,,76.8,,1565.9,26.19915,15398.5536,percent of total billed charges,
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,AETNA [1000108],AETNA [100010801],,,76.8,,832.19,26.19915,15398.5536,percent of total billed charges,
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,AETNA [1000108],AETNA [100010801],,,76.8,,171.81,26.19915,15398.5536,percent of total billed charges,
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,AETNA [1000108],AETNA [100010801],,,76.8,,199.33,26.19915,15398.5536,percent of total billed charges,
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,AETNA [1000108],AETNA [100010801],,,76.8,,231.24,26.19915,15398.5536,percent of total billed charges,
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,AETNA [1000108],AETNA [100010801],,,76.8,,432.49,26.19915,15398.5536,percent of total billed charges,
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,AETNA [1000108],AETNA [100010801],,,76.8,,914.86,26.19915,15398.5536,percent of total billed charges,
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,26.19915,15398.5536,percent of total billed charges,
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,26.19915,15398.5536,percent of total billed charges,
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,AETNA [1000108],AETNA [100010801],,,76.8,,15398.55,26.19915,15398.5536,percent of total billed charges,
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,AETNA [1000108],AETNA [100010801],,,76.8,,761.94,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,AETNA [1000108],AETNA [100010801],,,76.8,,4957.11,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,AETNA [1000108],AETNA [100010801],,,76.8,,1528.01,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,AETNA [1000108],AETNA [100010801],,,76.8,,1912.63,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,AETNA [1000108],AETNA [100010801],,,76.8,,1974.9,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,AETNA [1000108],AETNA [100010801],,,76.8,,1389.11,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,AETNA [1000108],AETNA [100010801],,,76.8,,1857.09,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,AETNA [1000108],AETNA [100010801],,,76.8,,2131.04,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,AETNA [1000108],AETNA [100010801],,,76.8,,2007.01,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,AETNA [1000108],AETNA [100010801],,,76.8,,2861.68,26.19915,15398.5536,percent of total billed charges,
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,AETNA [1000108],AETNA [100010801],,,76.8,,3527.19,26.19915,15398.5536,percent of total billed charges,
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,AETNA [1000108],AETNA [100010801],,,76.8,,3283,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,AETNA [1000108],AETNA [100010801],,,76.8,,3162.81,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,AETNA [1000108],AETNA [100010801],,,76.8,,4133.33,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,AETNA [1000108],AETNA [100010801],,,76.8,,4908.32,26.19915,15398.5536,percent of total billed charges,
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,AETNA [1000108],AETNA [100010801],,,76.8,,5772.19,26.19915,15398.5536,percent of total billed charges,
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,AETNA [1000108],AETNA [100010801],,,76.8,,1114.18,26.19915,15398.5536,percent of total billed charges,
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,AETNA [1000108],AETNA [100010801],,,76.8,,564.2,26.19915,15398.5536,percent of total billed charges,
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,AETNA [1000108],AETNA [100010801],,,76.8,,497.69,26.19915,15398.5536,percent of total billed charges,
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,AETNA [1000108],AETNA [100010801],,,76.8,,497.69,26.19915,15398.5536,percent of total billed charges,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,AETNA [1000108],AETNA [100010801],,,76.8,,902.98,26.19915,15398.5536,percent of total billed charges,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,AETNA [1000108],AETNA [100010801],,,76.8,,902.98,26.19915,15398.5536,percent of total billed charges,
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,AETNA [1000108],AETNA [100010801],,,76.8,,832.19,26.19915,15398.5536,percent of total billed charges,
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,AETNA [1000108],AETNA [100010801],,,76.8,,869.03,26.19915,15398.5536,percent of total billed charges,
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,AETNA [1000108],AETNA [100010801],,,76.8,,1061.74,26.19915,15398.5536,percent of total billed charges,
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,AETNA [1000108],AETNA [100010801],,,76.8,,1478.88,26.19915,15398.5536,percent of total billed charges,
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,AETNA [1000108],AETNA [100010801],,,76.8,,810.12,26.19915,15398.5536,percent of total billed charges,
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,AETNA [1000108],AETNA [100010801],,,76.8,,698.08,26.19915,15398.5536,percent of total billed charges,
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,AETNA [1000108],AETNA [100010801],,,76.8,,1959.01,26.19915,15398.5536,percent of total billed charges,
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,AETNA [1000108],AETNA [100010801],,,76.8,,6323.22,26.19915,15398.5536,percent of total billed charges,
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,AETNA [1000108],AETNA [100010801],,,76.8,,3611.21,26.19915,15398.5536,percent of total billed charges,
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,AETNA [1000108],AETNA [100010801],,,76.8,,684.52,200.09685,4563.1488,percent of total billed charges,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,AETNA [1000108],AETNA [100010801],,,76.8,,16168.48,399.86,21372.62592,percent of total billed charges,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,AETNA [1000108],AETNA [100010801],,,76.8,,8617.49,399.86,21372.62592,percent of total billed charges,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,AETNA [1000108],AETNA [100010801],,,76.8,,11192.47,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,AETNA [1000108],AETNA [100010801],,,76.8,,7167.63,399.86,21372.62592,percent of total billed charges,
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,AETNA [1000108],AETNA [100010801],,,76.8,,21372.63,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,AETNA [1000108],AETNA [100010801],,,76.8,,10630.7,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,AETNA [1000108],AETNA [100010801],,,76.8,,10630.7,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,AETNA [1000108],AETNA [100010801],,,76.8,,7167.63,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,76.8,,12546.97,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,AETNA [1000108],AETNA [100010801],,,76.8,,21372.63,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA [1000108],AETNA [100010801],,,76.8,,12724.19,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA [1000108],AETNA [100010801],,,76.8,,12724.19,399.86,21372.62592,percent of total billed charges,
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,21372.62592,percent of total billed charges,
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,AETNA [1000108],AETNA [100010801],,,76.8,,7174.59,399.86,21372.62592,percent of total billed charges,
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,AETNA [1000108],AETNA [100010801],,,76.8,,9569.92,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,AETNA [1000108],AETNA [100010801],,,76.8,,7174.59,399.86,21372.62592,percent of total billed charges,
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,AETNA [1000108],AETNA [100010801],,,76.8,,7252.15,399.86,21372.62592,percent of total billed charges,
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,AETNA [1000108],AETNA [100010801],,,76.8,,9552.81,399.86,21372.62592,percent of total billed charges,
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,AETNA [1000108],AETNA [100010801],,,76.8,,8041.47,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,AETNA [1000108],AETNA [100010801],,,76.8,,9552.81,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,AETNA [1000108],AETNA [100010801],,,76.8,,8242.51,399.86,21372.62592,percent of total billed charges,
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,AETNA [1000108],AETNA [100010801],,,76.8,,18142.2,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,AETNA [1000108],AETNA [100010801],,,76.8,,13393.89,399.86,21372.62592,percent of total billed charges,
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,76.8,,13402.44,399.86,21372.62592,percent of total billed charges,
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,AETNA [1000108],AETNA [100010801],,,76.8,,11038.48,399.86,21372.62592,percent of total billed charges,
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,399.86,21372.62592,percent of total billed charges,
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,AETNA [1000108],AETNA [100010801],,,76.8,,15669.46,399.86,21372.62592,percent of total billed charges,
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,AETNA [1000108],AETNA [100010801],,,76.8,,15227.46,399.86,21372.62592,percent of total billed charges,
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,399.86,21372.62592,percent of total billed charges,
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,399.86,21372.62592,percent of total billed charges,
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,21372.62592,percent of total billed charges,
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,76.8,,13402.44,399.86,46489.17504,percent of total billed charges,
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,AETNA [1000108],AETNA [100010801],,,76.8,,12404.39,399.86,46489.17504,percent of total billed charges,
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,AETNA [1000108],AETNA [100010801],,,76.8,,8434.98,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,AETNA [1000108],AETNA [100010801],,,76.8,,8031.14,399.86,46489.17504,percent of total billed charges,
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,AETNA [1000108],AETNA [100010801],,,76.8,,9056.63,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA [1000108],AETNA [100010801],,,76.8,,6553.53,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA [1000108],AETNA [100010801],,,76.8,,6553.53,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA [1000108],AETNA [100010801],,,76.8,,6553.53,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,76.8,,11406.34,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,AETNA [1000108],AETNA [100010801],,,76.8,,7643.27,399.86,46489.17504,percent of total billed charges,
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,AETNA [1000108],AETNA [100010801],,,76.8,,9598.43,399.86,46489.17504,percent of total billed charges,
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,AETNA [1000108],AETNA [100010801],,,76.8,,6834.95,399.86,46489.17504,percent of total billed charges,
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,AETNA [1000108],AETNA [100010801],,,76.8,,8372.25,399.86,46489.17504,percent of total billed charges,
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,399.86,46489.17504,percent of total billed charges,
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,46489.17504,percent of total billed charges,
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA [1000108],AETNA [100010801],,,76.8,,28515.84,399.86,46489.17504,percent of total billed charges,
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,AETNA [1000108],AETNA [100010801],,,76.8,,20367.55,399.86,46489.17504,percent of total billed charges,
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,AETNA [1000108],AETNA [100010801],,,76.8,,29840.83,399.86,46489.17504,percent of total billed charges,
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,AETNA [1000108],AETNA [100010801],,,76.8,,20367.55,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,AETNA [1000108],AETNA [100010801],,,76.8,,7200.25,399.86,46489.17504,percent of total billed charges,
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,AETNA [1000108],AETNA [100010801],,,76.8,,7200.25,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,399.86,46489.17504,percent of total billed charges,
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,46489.17504,percent of total billed charges,
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,AETNA [1000108],AETNA [100010801],,,76.8,,9897.85,399.86,46489.17504,percent of total billed charges,
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,AETNA [1000108],AETNA [100010801],,,76.8,,18235.88,399.86,46489.17504,percent of total billed charges,
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,AETNA [1000108],AETNA [100010801],,,76.8,,46489.18,399.86,46489.17504,percent of total billed charges,
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,46489.17504,percent of total billed charges,
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,AETNA [1000108],AETNA [100010801],,,76.8,,1244.28,22.2704,1965.53472,percent of total billed charges,
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,AETNA [1000108],AETNA [100010801],,,76.8,,1856.85,22.2704,1965.53472,percent of total billed charges,
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,AETNA [1000108],AETNA [100010801],,,76.8,,1780.28,22.2704,1965.53472,percent of total billed charges,
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,AETNA [1000108],AETNA [100010801],,,76.8,,1721.94,22.2704,1965.53472,percent of total billed charges,
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,AETNA [1000108],AETNA [100010801],,,76.8,,1722.88,22.2704,1965.53472,percent of total billed charges,
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,AETNA [1000108],AETNA [100010801],,,76.8,,1722.88,22.2704,1965.53472,percent of total billed charges,
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,AETNA [1000108],AETNA [100010801],,,76.8,,1965.53,22.2704,1965.53472,percent of total billed charges,
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,AETNA [1000108],AETNA [100010801],,,76.8,,76.19,22.2704,1965.53472,percent of total billed charges,
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,AETNA [1000108],AETNA [100010801],,,76.8,,968.85,22.2704,1965.53472,percent of total billed charges,
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,AETNA [1000108],AETNA [100010801],,,76.8,,968.85,22.2704,1965.53472,percent of total billed charges,
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,AETNA [1000108],AETNA [100010801],,,76.8,,1461.41,22.2704,1965.53472,percent of total billed charges,
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,22.2704,1965.53472,percent of total billed charges,
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,22.2704,1965.53472,percent of total billed charges,
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,22.2704,1965.53472,percent of total billed charges,
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,22.2704,1965.53472,percent of total billed charges,
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,22.2704,1965.53472,percent of total billed charges,
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,22.2704,1965.53472,percent of total billed charges,
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,22.2704,1965.53472,percent of total billed charges,
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,22.2704,1965.53472,percent of total billed charges,
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,76.8,,1119.47,22.2704,1965.53472,percent of total billed charges,
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,22.2704,1965.53472,percent of total billed charges,
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA [1000108],AETNA [100010801],,,76.8,,1078.76,22.2704,1965.53472,percent of total billed charges,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA [1000108],AETNA [100010801],,,76.8,,1994.69,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA [1000108],AETNA [100010801],,,76.8,,3318.12,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA [1000108],AETNA [100010801],,,76.8,,3318.12,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA [1000108],AETNA [100010801],,,76.8,,3318.12,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,261.9915,4400.1792,percent of total billed charges,
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,AETNA [1000108],AETNA [100010801],,,76.8,,2786.49,261.9915,4400.1792,percent of total billed charges,
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,AETNA [1000108],AETNA [100010801],,,76.8,,1257.87,261.9915,4400.1792,percent of total billed charges,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,261.9915,4400.1792,percent of total billed charges,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,261.9915,4400.1792,percent of total billed charges,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,261.9915,4400.1792,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,261.9915,4400.1792,percent of total billed charges,
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,261.9915,4400.1792,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,AETNA [1000108],AETNA [100010801],,,76.8,,3676.59,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,AETNA [1000108],AETNA [100010801],,,76.8,,4318.69,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,AETNA [1000108],AETNA [100010801],,,76.8,,4002.53,261.9915,4400.1792,percent of total billed charges,
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,AETNA [1000108],AETNA [100010801],,,76.8,,4002.53,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,AETNA [1000108],AETNA [100010801],,,76.8,,15683.71,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,AETNA [1000108],AETNA [100010801],,,76.8,,16311.06,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,AETNA [1000108],AETNA [100010801],,,76.8,,21779.07,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,AETNA [1000108],AETNA [100010801],,,76.8,,9310.43,150.646235,27674.62656,percent of total billed charges,
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,AETNA [1000108],AETNA [100010801],,,76.8,,9823.71,150.646235,27674.62656,percent of total billed charges,
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,150.646235,27674.62656,percent of total billed charges,
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,AETNA [1000108],AETNA [100010801],,,76.8,,24386.12,150.646235,27674.62656,percent of total billed charges,
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,AETNA [1000108],AETNA [100010801],,,76.8,,26383.09,150.646235,27674.62656,percent of total billed charges,
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,AETNA [1000108],AETNA [100010801],,,76.8,,24386.12,150.646235,27674.62656,percent of total billed charges,
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,AETNA [1000108],AETNA [100010801],,,76.8,,9310.43,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,AETNA [1000108],AETNA [100010801],,,76.8,,11902.51,150.646235,27674.62656,percent of total billed charges,
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,AETNA [1000108],AETNA [100010801],,,76.8,,19353.91,150.646235,27674.62656,percent of total billed charges,
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,AETNA [1000108],AETNA [100010801],,,76.8,,24166.34,150.646235,27674.62656,percent of total billed charges,
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,AETNA [1000108],AETNA [100010801],,,76.8,,20509.66,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,AETNA [1000108],AETNA [100010801],,,76.8,,21921.17,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,AETNA [1000108],AETNA [100010801],,,76.8,,27674.63,150.646235,27674.62656,percent of total billed charges,
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,AETNA [1000108],AETNA [100010801],,,76.8,,24848.42,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,AETNA [1000108],AETNA [100010801],,,76.8,,19353.91,150.646235,27674.62656,percent of total billed charges,
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,AETNA [1000108],AETNA [100010801],,,76.8,,25151.56,150.646235,27674.62656,percent of total billed charges,
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,150.646235,27674.62656,percent of total billed charges,
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,AETNA [1000108],AETNA [100010801],,,76.8,,4302.4,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,AETNA [1000108],AETNA [100010801],,,76.8,,18820.45,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,AETNA [1000108],AETNA [100010801],,,76.8,,20545.67,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,AETNA [1000108],AETNA [100010801],,,76.8,,18820.45,150.646235,27674.62656,percent of total billed charges,
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,AETNA [1000108],AETNA [100010801],,,76.8,,1925.48,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,AETNA [1000108],AETNA [100010801],,,76.8,,5329.11,150.646235,27674.62656,percent of total billed charges,
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,AETNA [1000108],AETNA [100010801],,,76.8,,20702.5,150.646235,27674.62656,percent of total billed charges,
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,AETNA [1000108],AETNA [100010801],,,76.8,,20702.5,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,AETNA [1000108],AETNA [100010801],,,76.8,,21158.75,150.646235,27674.62656,percent of total billed charges,
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,AETNA [1000108],AETNA [100010801],,,76.8,,20545.67,150.646235,27674.62656,percent of total billed charges,
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,AETNA [1000108],AETNA [100010801],,,76.8,,23448.26,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,76.8,,12546.97,399.86,21443.91168,percent of total billed charges,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,AETNA [1000108],AETNA [100010801],,,76.8,,20659.73,399.86,21443.91168,percent of total billed charges,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,AETNA [1000108],AETNA [100010801],,,76.8,,21443.91,399.86,21443.91168,percent of total billed charges,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,AETNA [1000108],AETNA [100010801],,,76.8,,21443.91,399.86,21443.91168,percent of total billed charges,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,AETNA [1000108],AETNA [100010801],,,76.8,,20417.34,399.86,21443.91168,percent of total billed charges,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,AETNA [1000108],AETNA [100010801],,,76.8,,19918.32,399.86,21443.91168,percent of total billed charges,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,AETNA [1000108],AETNA [100010801],,,76.8,,361.57,99.62861,33156.48,percent of total billed charges,
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,AETNA [1000108],AETNA [100010801],,,76.8,,361.57,99.62861,33156.48,percent of total billed charges,
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,AETNA [1000108],AETNA [100010801],,,76.8,,340.82,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,99.62861,33156.48,percent of total billed charges,
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,99.62861,33156.48,percent of total billed charges,
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,AETNA [1000108],AETNA [100010801],,,76.8,,3976.46,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,AETNA [1000108],AETNA [100010801],,,76.8,,3050.47,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,AETNA [1000108],AETNA [100010801],,,76.8,,3050.47,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,99.62861,33156.48,percent of total billed charges,
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,AETNA [1000108],AETNA [100010801],,,76.8,,3591.85,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,AETNA [1000108],AETNA [100010801],,,,,,45.06164,416.02,other,Implant Exclusions
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,AETNA [1000108],AETNA [100010801],,,,,,45.06164,416.02,other,Implant Exclusions
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,,,,45.06164,416.02,other,Implant Exclusions
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,,,,45.06164,416.02,other,Implant Exclusions
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,AETNA [1000108],AETNA [100010801],,,76.8,,35051.14,399.86,41625.59232,percent of total billed charges,
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,399.86,41625.59232,percent of total billed charges,
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,AETNA [1000108],AETNA [100010801],,,76.8,,23891.61,399.86,41625.59232,percent of total billed charges,
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,41625.59232,percent of total billed charges,
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,AETNA [1000108],AETNA [100010801],,,76.8,,29897.67,399.86,41625.59232,percent of total billed charges,
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,41625.59232,percent of total billed charges,
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,41625.59232,percent of total billed charges,
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,41625.59232,percent of total billed charges,
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,AETNA [1000108],AETNA [100010801],,,76.8,,41625.59,399.86,41625.59232,percent of total billed charges,
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA [1000108],AETNA [100010801],,,76.8,,19675.93,399.86,19675.9296,percent of total billed charges,
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA [1000108],AETNA [100010801],,,76.8,,19675.93,399.86,19675.9296,percent of total billed charges,
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA [1000108],AETNA [100010801],,,76.8,,19675.93,399.86,19675.9296,percent of total billed charges,
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,399.86,19675.9296,percent of total billed charges,
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,399.86,19675.9296,percent of total billed charges,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,399.86,19675.9296,percent of total billed charges,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,399.86,19675.9296,percent of total billed charges,
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,AETNA [1000108],AETNA [100010801],,,76.8,,8618.2,399.86,19675.9296,percent of total billed charges,
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,AETNA [1000108],AETNA [100010801],,,76.8,,11408.47,399.86,19675.9296,percent of total billed charges,
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,AETNA [1000108],AETNA [100010801],,,76.8,,15050.66,399.86,19675.9296,percent of total billed charges,
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,AETNA [1000108],AETNA [100010801],,,76.8,,15050.66,399.86,19675.9296,percent of total billed charges,
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA [1000108],AETNA [100010801],,,76.8,,8868.43,399.86,19675.9296,percent of total billed charges,
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA [1000108],AETNA [100010801],,,76.8,,8868.43,399.86,19675.9296,percent of total billed charges,
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,AETNA [1000108],AETNA [100010801],,,76.8,,7604.16,399.86,19675.9296,percent of total billed charges,
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,399.86,19675.9296,percent of total billed charges,
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,399.86,19675.9296,percent of total billed charges,
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,AETNA [1000108],AETNA [100010801],,,76.8,,15113.4,399.86,19675.9296,percent of total billed charges,
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,19675.9296,percent of total billed charges,
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,19675.9296,percent of total billed charges,
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,19675.9296,percent of total billed charges,
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,19675.9296,percent of total billed charges,
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,399.86,19675.9296,percent of total billed charges,
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,399.86,19675.9296,percent of total billed charges,
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,399.86,19675.9296,percent of total billed charges,
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,399.86,19675.9296,percent of total billed charges,
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,399.86,19675.9296,percent of total billed charges,
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,399.86,19675.9296,percent of total billed charges,
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,AETNA [1000108],AETNA [100010801],,,76.8,,15113.4,399.86,19675.9296,percent of total billed charges,
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,19675.9296,percent of total billed charges,
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,AETNA [1000108],AETNA [100010801],,,76.8,,8982.49,399.86,19675.9296,percent of total billed charges,
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA [1000108],AETNA [100010801],,,76.8,,46419.07,399.86,46419.072,percent of total billed charges,
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,399.86,46419.072,percent of total billed charges,
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA [1000108],AETNA [100010801],,,76.8,,46419.07,399.86,46419.072,percent of total billed charges,
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA [1000108],AETNA [100010801],,,76.8,,46419.07,399.86,46419.072,percent of total billed charges,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,AETNA [1000108],AETNA [100010801],,,76.8,,27375.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,AETNA [1000108],AETNA [100010801],,,76.8,,22913.97,232.64935,38052.27264,percent of total billed charges,
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,AETNA [1000108],AETNA [100010801],,,76.8,,9575.62,232.64935,38052.27264,percent of total billed charges,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,AETNA [1000108],AETNA [100010801],,,76.8,,10137.38,232.64935,38052.27264,percent of total billed charges,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,AETNA [1000108],AETNA [100010801],,,76.8,,9575.62,232.64935,38052.27264,percent of total billed charges,
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,AETNA [1000108],AETNA [100010801],,,76.8,,9096.55,232.64935,38052.27264,percent of total billed charges,
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,AETNA [1000108],AETNA [100010801],,,76.8,,14985.08,232.64935,38052.27264,percent of total billed charges,
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,AETNA [1000108],AETNA [100010801],,,76.8,,28103.22,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA [1000108],AETNA [100010801],,,76.8,,8780.03,232.64935,38052.27264,percent of total billed charges,
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA [1000108],AETNA [100010801],,,76.8,,8780.03,232.64935,38052.27264,percent of total billed charges,
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA [1000108],AETNA [100010801],,,76.8,,8780.03,232.64935,38052.27264,percent of total billed charges,
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA [1000108],AETNA [100010801],,,76.8,,8780.03,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,AETNA [1000108],AETNA [100010801],,,76.8,,6333,232.64935,38052.27264,percent of total billed charges,
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,AETNA [1000108],AETNA [100010801],,,76.8,,11310.1,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,AETNA [1000108],AETNA [100010801],,,76.8,,11580.99,232.64935,38052.27264,percent of total billed charges,
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,AETNA [1000108],AETNA [100010801],,,76.8,,12889.44,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,AETNA [1000108],AETNA [100010801],,,76.8,,12596.87,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA [1000108],AETNA [100010801],,,76.8,,17337.63,232.64935,38052.27264,percent of total billed charges,
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,AETNA [1000108],AETNA [100010801],,,76.8,,17594.99,232.64935,38052.27264,percent of total billed charges,
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,AETNA [1000108],AETNA [100010801],,,76.8,,13341.85,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,AETNA [1000108],AETNA [100010801],,,76.8,,13477.3,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,AETNA [1000108],AETNA [100010801],,,76.8,,18980.14,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,AETNA [1000108],AETNA [100010801],,,76.8,,13875.53,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,AETNA [1000108],AETNA [100010801],,,76.8,,13271.27,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,AETNA [1000108],AETNA [100010801],,,76.8,,13477.3,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,AETNA [1000108],AETNA [100010801],,,76.8,,14016.39,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA [1000108],AETNA [100010801],,,76.8,,17337.63,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,AETNA [1000108],AETNA [100010801],,,76.8,,13341.85,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,AETNA [1000108],AETNA [100010801],,,76.8,,7676.47,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,AETNA [1000108],AETNA [100010801],,,76.8,,7546.31,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,AETNA [1000108],AETNA [100010801],,,76.8,,7739.2,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,AETNA [1000108],AETNA [100010801],,,76.8,,7739.2,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA [1000108],AETNA [100010801],,,76.8,,11206.73,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,AETNA [1000108],AETNA [100010801],,,76.8,,5410.59,232.64935,38052.27264,percent of total billed charges,
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA [1000108],AETNA [100010801],,,76.8,,11206.73,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,AETNA [1000108],AETNA [100010801],,,76.8,,18575.22,232.64935,38052.27264,percent of total billed charges,
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA [1000108],AETNA [100010801],,,76.8,,6437.27,232.64935,38052.27264,percent of total billed charges,
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA [1000108],AETNA [100010801],,,76.8,,7154.33,232.64935,38052.27264,percent of total billed charges,
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA [1000108],AETNA [100010801],,,76.8,,4214.36,232.64935,38052.27264,percent of total billed charges,
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,AETNA [1000108],AETNA [100010801],,,76.8,,5361.67,232.64935,38052.27264,percent of total billed charges,
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA [1000108],AETNA [100010801],,,76.8,,6437.27,232.64935,38052.27264,percent of total billed charges,
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA [1000108],AETNA [100010801],,,76.8,,7154.33,232.64935,38052.27264,percent of total billed charges,
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA [1000108],AETNA [100010801],,,76.8,,4214.36,232.64935,38052.27264,percent of total billed charges,
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA [1000108],AETNA [100010801],,,76.8,,6437.27,232.64935,38052.27264,percent of total billed charges,
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA [1000108],AETNA [100010801],,,76.8,,7154.33,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,AETNA [1000108],AETNA [100010801],,,76.8,,5971.21,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,AETNA [1000108],AETNA [100010801],,,76.8,,23417.21,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,AETNA [1000108],AETNA [100010801],,,76.8,,18036.27,232.64935,38052.27264,percent of total billed charges,
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,AETNA [1000108],AETNA [100010801],,,76.8,,38052.27,232.64935,38052.27264,percent of total billed charges,
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,AETNA [1000108],AETNA [100010801],,,76.8,,33656.67,232.64935,38052.27264,percent of total billed charges,
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,AETNA [1000108],AETNA [100010801],,,76.8,,26519.73,232.64935,38052.27264,percent of total billed charges,
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA [1000108],AETNA [100010801],,,76.8,,8797.14,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA [1000108],AETNA [100010801],,,76.8,,8797.14,232.64935,38052.27264,percent of total billed charges,
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,232.64935,38052.27264,percent of total billed charges,
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,AETNA [1000108],AETNA [100010801],,,76.8,,22913.97,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,AETNA [1000108],AETNA [100010801],,,76.8,,7121.77,232.64935,38052.27264,percent of total billed charges,
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,AETNA [1000108],AETNA [100010801],,,76.8,,23765.1,232.64935,38052.27264,percent of total billed charges,
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,AETNA [1000108],AETNA [100010801],,,76.8,,23765.1,232.64935,38052.27264,percent of total billed charges,
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,AETNA [1000108],AETNA [100010801],,,76.8,,7558.49,232.64935,38052.27264,percent of total billed charges,
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,232.64935,38052.27264,percent of total billed charges,
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,232.64935,38052.27264,percent of total billed charges,
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA [1000108],AETNA [100010801],,,76.8,,7399.86,232.64935,38052.27264,percent of total billed charges,
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA [1000108],AETNA [100010801],,,76.8,,7399.86,232.64935,38052.27264,percent of total billed charges,
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA [1000108],AETNA [100010801],,,76.8,,8255.34,232.64935,38052.27264,percent of total billed charges,
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,AETNA [1000108],AETNA [100010801],,,76.8,,10536.61,232.64935,38052.27264,percent of total billed charges,
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,232.64935,38052.27264,percent of total billed charges,
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,232.64935,38052.27264,percent of total billed charges,
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA [1000108],AETNA [100010801],,,76.8,,7399.86,232.64935,38052.27264,percent of total billed charges,
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA [1000108],AETNA [100010801],,,76.8,,7399.86,232.64935,38052.27264,percent of total billed charges,
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA [1000108],AETNA [100010801],,,76.8,,8255.34,232.64935,38052.27264,percent of total billed charges,
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,AETNA [1000108],AETNA [100010801],,,76.8,,10536.61,232.64935,38052.27264,percent of total billed charges,
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,AETNA [1000108],AETNA [100010801],,,76.8,,5465.12,232.64935,38052.27264,percent of total billed charges,
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,232.64935,38052.27264,percent of total billed charges,
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,232.64935,38052.27264,percent of total billed charges,
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,232.64935,38052.27264,percent of total billed charges,
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,232.64935,38052.27264,percent of total billed charges,
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,232.64935,38052.27264,percent of total billed charges,
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,232.64935,38052.27264,percent of total billed charges,
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,AETNA [1000108],AETNA [100010801],,,76.8,,1723.16,232.64935,38052.27264,percent of total billed charges,
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,AETNA [1000108],AETNA [100010801],,,76.8,,1723.16,232.64935,38052.27264,percent of total billed charges,
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,AETNA [1000108],AETNA [100010801],,,76.8,,2013.82,232.64935,38052.27264,percent of total billed charges,
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,232.64935,38052.27264,percent of total billed charges,
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,AETNA [1000108],AETNA [100010801],,,76.8,,795.88,232.64935,38052.27264,percent of total billed charges,
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,AETNA [1000108],AETNA [100010801],,,76.8,,6622.63,232.64935,38052.27264,percent of total billed charges,
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,AETNA [1000108],AETNA [100010801],,,76.8,,7153.85,232.64935,38052.27264,percent of total billed charges,
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,AETNA [1000108],AETNA [100010801],,,76.8,,13299.79,232.64935,38052.27264,percent of total billed charges,
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,AETNA [1000108],AETNA [100010801],,,76.8,,15098.28,232.64935,38052.27264,percent of total billed charges,
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,AETNA [1000108],AETNA [100010801],,,76.8,,15098.28,232.64935,38052.27264,percent of total billed charges,
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,AETNA [1000108],AETNA [100010801],,,76.8,,5580.47,232.64935,38052.27264,percent of total billed charges,
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA [1000108],AETNA [100010801],,,76.8,,7494.74,232.64935,38052.27264,percent of total billed charges,
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA [1000108],AETNA [100010801],,,76.8,,7494.74,232.64935,38052.27264,percent of total billed charges,
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA [1000108],AETNA [100010801],,,76.8,,7494.74,232.64935,38052.27264,percent of total billed charges,
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA [1000108],AETNA [100010801],,,76.8,,7494.74,232.64935,38052.27264,percent of total billed charges,
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,AETNA [1000108],AETNA [100010801],,,76.8,,7403.34,232.64935,38052.27264,percent of total billed charges,
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,AETNA [1000108],AETNA [100010801],,,76.8,,9022.41,232.64935,38052.27264,percent of total billed charges,
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,AETNA [1000108],AETNA [100010801],,,76.8,,7046.81,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,76.8,,2291.52,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,76.8,,2291.52,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,76.8,,2291.52,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,76.8,,2291.52,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,AETNA [1000108],AETNA [100010801],,,76.8,,3749.93,232.64935,38052.27264,percent of total billed charges,
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA [1000108],AETNA [100010801],,,76.8,,10702,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA [1000108],AETNA [100010801],,,76.8,,10702,232.64935,38052.27264,percent of total billed charges,
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA [1000108],AETNA [100010801],,,76.8,,10702,232.64935,38052.27264,percent of total billed charges,
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,AETNA [1000108],AETNA [100010801],,,76.8,,13556.43,232.64935,38052.27264,percent of total billed charges,
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,AETNA [1000108],AETNA [100010801],,,76.8,,13556.43,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA [1000108],AETNA [100010801],,,76.8,,8839.91,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,76.8,,8412.17,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,AETNA [1000108],AETNA [100010801],,,76.8,,24653.26,232.64935,38052.27264,percent of total billed charges,
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,AETNA [1000108],AETNA [100010801],,,76.8,,23417.21,232.64935,38052.27264,percent of total billed charges,
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,AETNA [1000108],AETNA [100010801],,,76.8,,24118.69,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,AETNA [1000108],AETNA [100010801],,,76.8,,22387.78,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA [1000108],AETNA [100010801],,,76.8,,8797.14,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,AETNA [1000108],AETNA [100010801],,,76.8,,12584.04,232.64935,38052.27264,percent of total billed charges,
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,232.64935,38052.27264,percent of total billed charges,
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,AETNA [1000108],AETNA [100010801],,,76.8,,7046.81,232.64935,38052.27264,percent of total billed charges,
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,AETNA [1000108],AETNA [100010801],,,76.8,,6349.42,232.64935,38052.27264,percent of total billed charges,
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,AETNA [1000108],AETNA [100010801],,,76.8,,31233.69,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,AETNA [1000108],AETNA [100010801],,,76.8,,31233.41,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,AETNA [1000108],AETNA [100010801],,,76.8,,9264.8,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA [1000108],AETNA [100010801],,,76.8,,9333.24,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,AETNA [1000108],AETNA [100010801],,,76.8,,10727.66,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA [1000108],AETNA [100010801],,,76.8,,9333.24,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA [1000108],AETNA [100010801],,,76.8,,9333.24,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,AETNA [1000108],AETNA [100010801],,,76.8,,10727.66,232.64935,38052.27264,percent of total billed charges,
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,AETNA [1000108],AETNA [100010801],,,76.8,,9050.93,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,AETNA [1000108],AETNA [100010801],,,76.8,,11132.58,232.64935,38052.27264,percent of total billed charges,
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,AETNA [1000108],AETNA [100010801],,,76.8,,9914.96,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,AETNA [1000108],AETNA [100010801],,,76.8,,9914.96,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,AETNA [1000108],AETNA [100010801],,,76.8,,8654.56,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,AETNA [1000108],AETNA [100010801],,,76.8,,11018.52,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,AETNA [1000108],AETNA [100010801],,,76.8,,18090.45,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,AETNA [1000108],AETNA [100010801],,,76.8,,11018.52,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,AETNA [1000108],AETNA [100010801],,,76.8,,8389.36,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,AETNA [1000108],AETNA [100010801],,,76.8,,9558.51,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,AETNA [1000108],AETNA [100010801],,,76.8,,8962.53,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,AETNA [1000108],AETNA [100010801],,,76.8,,9800.89,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,AETNA [1000108],AETNA [100010801],,,76.8,,11432,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,AETNA [1000108],AETNA [100010801],,,76.8,,18660.76,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,AETNA [1000108],AETNA [100010801],,,76.8,,10294.22,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,AETNA [1000108],AETNA [100010801],,,76.8,,10924.42,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,AETNA [1000108],AETNA [100010801],,,76.8,,17933.61,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,AETNA [1000108],AETNA [100010801],,,76.8,,9390.27,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,232.64935,38052.27264,percent of total billed charges,
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,AETNA [1000108],AETNA [100010801],,,76.8,,20286.17,232.64935,38052.27264,percent of total billed charges,
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA [1000108],AETNA [100010801],,,76.8,,35041.67,232.64935,38052.27264,percent of total billed charges,
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA [1000108],AETNA [100010801],,,76.8,,35041.67,232.64935,38052.27264,percent of total billed charges,
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA [1000108],AETNA [100010801],,,76.8,,35041.67,232.64935,38052.27264,percent of total billed charges,
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,232.64935,38052.27264,percent of total billed charges,
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA [1000108],AETNA [100010801],,,76.8,,11206.73,232.64935,38052.27264,percent of total billed charges,
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA [1000108],AETNA [100010801],,,76.8,,11206.73,232.64935,38052.27264,percent of total billed charges,
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA [1000108],AETNA [100010801],,,76.8,,6437.27,232.64935,38052.27264,percent of total billed charges,
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,AETNA [1000108],AETNA [100010801],,,76.8,,5361.67,232.64935,38052.27264,percent of total billed charges,
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA [1000108],AETNA [100010801],,,76.8,,5850.61,232.64935,38052.27264,percent of total billed charges,
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA [1000108],AETNA [100010801],,,76.8,,5850.61,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,AETNA [1000108],AETNA [100010801],,,76.8,,11049.89,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA [1000108],AETNA [100010801],,,76.8,,2144.86,26.19915,32197.7856,percent of total billed charges,
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA [1000108],AETNA [100010801],,,76.8,,2144.86,26.19915,32197.7856,percent of total billed charges,
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA [1000108],AETNA [100010801],,,76.8,,2144.86,26.19915,32197.7856,percent of total billed charges,
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,76.8,,134.44,26.19915,32197.7856,percent of total billed charges,
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA [1000108],AETNA [100010801],,,76.8,,5296.51,26.19915,32197.7856,percent of total billed charges,
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA [1000108],AETNA [100010801],,,76.8,,5296.51,26.19915,32197.7856,percent of total billed charges,
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA [1000108],AETNA [100010801],,,76.8,,5296.51,26.19915,32197.7856,percent of total billed charges,
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,AETNA [1000108],AETNA [100010801],,,76.8,,7089.18,26.19915,32197.7856,percent of total billed charges,
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,26.19915,32197.7856,percent of total billed charges,
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,26.19915,32197.7856,percent of total billed charges,
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,26.19915,32197.7856,percent of total billed charges,
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,26.19915,32197.7856,percent of total billed charges,
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,AETNA [1000108],AETNA [100010801],,,76.8,,8463.5,26.19915,32197.7856,percent of total billed charges,
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,26.19915,32197.7856,percent of total billed charges,
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,26.19915,32197.7856,percent of total billed charges,
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,AETNA [1000108],AETNA [100010801],,,76.8,,3098.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,AETNA [1000108],AETNA [100010801],,,76.8,,443.6,26.19915,32197.7856,percent of total billed charges,
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,AETNA [1000108],AETNA [100010801],,,76.8,,490.65,26.19915,32197.7856,percent of total billed charges,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,AETNA [1000108],AETNA [100010801],,,76.8,,32197.79,26.19915,32197.7856,percent of total billed charges,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,AETNA [1000108],AETNA [100010801],,,76.8,,32197.79,26.19915,32197.7856,percent of total billed charges,
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,AETNA [1000108],AETNA [100010801],,,76.8,,28660.46,26.19915,32197.7856,percent of total billed charges,
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,AETNA [1000108],AETNA [100010801],,,76.8,,6825.17,26.19915,32197.7856,percent of total billed charges,
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,AETNA [1000108],AETNA [100010801],,,76.8,,6156.96,26.19915,32197.7856,percent of total billed charges,
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,AETNA [1000108],AETNA [100010801],,,76.8,,6156.96,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,AETNA [1000108],AETNA [100010801],,,76.8,,2529.84,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,26.19915,32197.7856,percent of total billed charges,
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,AETNA [1000108],AETNA [100010801],,,76.8,,6926.21,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,26.19915,32197.7856,percent of total billed charges,
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,AETNA [1000108],AETNA [100010801],,,76.8,,5622.45,26.19915,32197.7856,percent of total billed charges,
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,26.19915,32197.7856,percent of total billed charges,
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,26.19915,32197.7856,percent of total billed charges,
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,AETNA [1000108],AETNA [100010801],,,76.8,,5709.51,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,AETNA [1000108],AETNA [100010801],,,76.8,,4869.24,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,AETNA [1000108],AETNA [100010801],,,76.8,,3749.93,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA [1000108],AETNA [100010801],,,76.8,,3237.46,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA [1000108],AETNA [100010801],,,76.8,,3237.46,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA [1000108],AETNA [100010801],,,76.8,,3237.46,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA [1000108],AETNA [100010801],,,76.8,,3237.46,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,AETNA [1000108],AETNA [100010801],,,76.8,,3800.78,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,AETNA [1000108],AETNA [100010801],,,76.8,,9324.68,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA [1000108],AETNA [100010801],,,76.8,,5068.35,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA [1000108],AETNA [100010801],,,76.8,,5068.35,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA [1000108],AETNA [100010801],,,76.8,,5850.61,26.19915,32197.7856,percent of total billed charges,
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,26.19915,32197.7856,percent of total billed charges,
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA [1000108],AETNA [100010801],,,76.8,,5068.35,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,AETNA [1000108],AETNA [100010801],,,76.8,,4220.91,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,AETNA [1000108],AETNA [100010801],,,76.8,,4546.85,26.19915,32197.7856,percent of total billed charges,
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA [1000108],AETNA [100010801],,,76.8,,4214.36,26.19915,32197.7856,percent of total billed charges,
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,198.065125,7007.6928,percent of total billed charges,
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,76.8,,677.57,198.065125,7007.6928,percent of total billed charges,
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,AETNA [1000108],AETNA [100010801],,,76.8,,7007.69,198.065125,7007.6928,percent of total billed charges,
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,198.065125,7007.6928,percent of total billed charges,
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,AETNA [1000108],AETNA [100010801],,,76.8,,3061.47,198.065125,7007.6928,percent of total billed charges,
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,AETNA [1000108],AETNA [100010801],,,76.8,,2493.17,399.86,2621.49888,percent of total billed charges,
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,AETNA [1000108],AETNA [100010801],,,76.8,,2621.5,399.86,2621.49888,percent of total billed charges,
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,399.86,2621.49888,percent of total billed charges,
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,AETNA [1000108],AETNA [100010801],,,76.8,,2540.84,399.86,2621.49888,percent of total billed charges,
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,AETNA [1000108],AETNA [100010801],,,76.8,,45329.65,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,AETNA [1000108],AETNA [100010801],,,76.8,,31261.82,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,AETNA [1000108],AETNA [100010801],,,76.8,,31261.82,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,AETNA [1000108],AETNA [100010801],,,76.8,,24604,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,AETNA [1000108],AETNA [100010801],,,76.8,,30314.5,399.86,45329.64864,percent of total billed charges,
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,AETNA [1000108],AETNA [100010801],,,76.8,,26498.66,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA [1000108],AETNA [100010801],,,76.8,,27159.9,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA [1000108],AETNA [100010801],,,76.8,,27159.9,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA [1000108],AETNA [100010801],,,76.8,,33217.11,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA [1000108],AETNA [100010801],,,76.8,,27159.9,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA [1000108],AETNA [100010801],,,76.8,,27159.9,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA [1000108],AETNA [100010801],,,76.8,,33217.11,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA [1000108],AETNA [100010801],,,76.8,,33217.11,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,AETNA [1000108],AETNA [100010801],,,76.8,,23020.07,399.86,45329.64864,percent of total billed charges,
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,AETNA [1000108],AETNA [100010801],,,76.8,,36654.01,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,AETNA [1000108],AETNA [100010801],,,76.8,,23020.07,399.86,45329.64864,percent of total billed charges,
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,AETNA [1000108],AETNA [100010801],,,76.8,,27053.04,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,AETNA [1000108],AETNA [100010801],,,76.8,,27053.04,399.86,45329.64864,percent of total billed charges,
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,AETNA [1000108],AETNA [100010801],,,76.8,,27472.51,399.86,45329.64864,percent of total billed charges,
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,AETNA [1000108],AETNA [100010801],,,76.8,,27472.51,399.86,45329.64864,percent of total billed charges,
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,45329.64864,percent of total billed charges,
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA [1000108],AETNA [100010801],,,76.8,,21788.54,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,AETNA [1000108],AETNA [100010801],,,76.8,,37344.81,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,AETNA [1000108],AETNA [100010801],,,76.8,,30651.75,399.86,45329.64864,percent of total billed charges,
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,AETNA [1000108],AETNA [100010801],,,76.8,,28609.31,399.86,45329.64864,percent of total billed charges,
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,AETNA [1000108],AETNA [100010801],,,76.8,,38860.53,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,AETNA [1000108],AETNA [100010801],,,76.8,,38860.53,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA [1000108],AETNA [100010801],,,76.8,,32900.71,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA [1000108],AETNA [100010801],,,76.8,,32900.71,399.86,45329.64864,percent of total billed charges,
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA [1000108],AETNA [100010801],,,76.8,,32900.71,399.86,45329.64864,percent of total billed charges,
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA [1000108],AETNA [100010801],,,76.8,,37637.35,399.86,45329.64864,percent of total billed charges,
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA [1000108],AETNA [100010801],,,76.8,,37637.35,399.86,45329.64864,percent of total billed charges,
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA [1000108],AETNA [100010801],,,76.8,,37637.35,399.86,45329.64864,percent of total billed charges,
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,AETNA [1000108],AETNA [100010801],,,76.8,,38650.98,399.86,45329.64864,percent of total billed charges,
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,AETNA [1000108],AETNA [100010801],,,76.8,,38650.98,399.86,45329.64864,percent of total billed charges,
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,AETNA [1000108],AETNA [100010801],,,76.8,,36690.02,399.86,45329.64864,percent of total billed charges,
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,AETNA [1000108],AETNA [100010801],,,76.8,,36690.02,399.86,45329.64864,percent of total billed charges,
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,AETNA [1000108],AETNA [100010801],,,76.8,,41663.49,399.86,45329.64864,percent of total billed charges,
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA [1000108],AETNA [100010801],,,76.8,,37703.65,399.86,45329.64864,percent of total billed charges,
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA [1000108],AETNA [100010801],,,76.8,,37703.65,399.86,45329.64864,percent of total billed charges,
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA [1000108],AETNA [100010801],,,76.8,,37703.65,399.86,45329.64864,percent of total billed charges,
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,AETNA [1000108],AETNA [100010801],,,76.8,,37046.21,399.86,45329.64864,percent of total billed charges,
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,AETNA [1000108],AETNA [100010801],,,76.8,,40545.64,399.86,45329.64864,percent of total billed charges,
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,AETNA [1000108],AETNA [100010801],,,76.8,,38584.67,399.86,45329.64864,percent of total billed charges,
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,AETNA [1000108],AETNA [100010801],,,76.8,,30125.03,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA [1000108],AETNA [100010801],,,76.8,,24507.38,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,AETNA [1000108],AETNA [100010801],,,76.8,,32019.69,399.86,45329.64864,percent of total billed charges,
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA [1000108],AETNA [100010801],,,76.8,,24507.38,399.86,45329.64864,percent of total billed charges,
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA [1000108],AETNA [100010801],,,76.8,,24507.38,399.86,45329.64864,percent of total billed charges,
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA [1000108],AETNA [100010801],,,76.8,,24507.38,399.86,45329.64864,percent of total billed charges,
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,AETNA [1000108],AETNA [100010801],,,76.8,,25511.55,399.86,45329.64864,percent of total billed charges,
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA [1000108],AETNA [100010801],,,76.8,,37703.65,399.86,45329.64864,percent of total billed charges,
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,26.19915,3519.77472,percent of total billed charges,
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,26.19915,3519.77472,percent of total billed charges,
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,AETNA [1000108],AETNA [100010801],,,76.8,,829.04,26.19915,3519.77472,percent of total billed charges,
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA [1000108],AETNA [100010801],,,76.8,,2309.85,26.19915,3519.77472,percent of total billed charges,
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,26.19915,3519.77472,percent of total billed charges,
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,26.19915,3519.77472,percent of total billed charges,
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,26.19915,3519.77472,percent of total billed charges,
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,AETNA [1000108],AETNA [100010801],,,76.8,,829.04,26.19915,3519.77472,percent of total billed charges,
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,26.19915,3519.77472,percent of total billed charges,
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,AETNA [1000108],AETNA [100010801],,,,,,399.86,7592.15526,other,272 with C codes
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,AETNA [1000108],AETNA [100010801],,,,,,399.86,7592.15526,other,272 with C codes
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,7592.15526,other,272 with C codes
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,AETNA [1000108],AETNA [100010801],,,76.8,,960.71,9.77024,11406.336,percent of total billed charges,
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,AETNA [1000108],AETNA [100010801],,,76.8,,1230.6,9.77024,11406.336,percent of total billed charges,
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,AETNA [1000108],AETNA [100010801],,,76.8,,169.21,9.77024,11406.336,percent of total billed charges,
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,AETNA [1000108],AETNA [100010801],,,76.8,,34.68,9.77024,11406.336,percent of total billed charges,
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,AETNA [1000108],AETNA [100010801],,,76.8,,173.47,9.77024,11406.336,percent of total billed charges,
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,AETNA [1000108],AETNA [100010801],,,76.8,,33.42,9.77024,11406.336,percent of total billed charges,
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,AETNA [1000108],AETNA [100010801],,,76.8,,937.87,9.77024,11406.336,percent of total billed charges,
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,AETNA [1000108],AETNA [100010801],,,76.8,,855.16,9.77024,11406.336,percent of total billed charges,
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,AETNA [1000108],AETNA [100010801],,,76.8,,60.76,9.77024,11406.336,percent of total billed charges,
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA [1000108],AETNA [100010801],,,76.8,,369.48,9.77024,11406.336,percent of total billed charges,
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,AETNA [1000108],AETNA [100010801],,,76.8,,1044.12,9.77024,11406.336,percent of total billed charges,
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA [1000108],AETNA [100010801],,,76.8,,2742.49,9.77024,11406.336,percent of total billed charges,
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.77024,11406.336,percent of total billed charges,
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.77024,11406.336,percent of total billed charges,
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.77024,11406.336,percent of total billed charges,
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,AETNA [1000108],AETNA [100010801],,,76.8,,6290.63,9.77024,11406.336,percent of total billed charges,
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,AETNA [1000108],AETNA [100010801],,,76.8,,883.08,9.77024,11406.336,percent of total billed charges,
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,76.8,,11406.34,9.77024,11406.336,percent of total billed charges,
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,AETNA [1000108],AETNA [100010801],,,76.8,,443.6,9.77024,11406.336,percent of total billed charges,
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,AETNA [1000108],AETNA [100010801],,,76.8,,542.19,9.77024,11406.336,percent of total billed charges,
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,AETNA [1000108],AETNA [100010801],,,76.8,,287.25,9.77024,11406.336,percent of total billed charges,
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.77024,11406.336,percent of total billed charges,
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,AETNA [1000108],AETNA [100010801],,,76.8,,1074.28,9.77024,11406.336,percent of total billed charges,
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,AETNA [1000108],AETNA [100010801],,,76.8,,1746.36,9.77024,11406.336,percent of total billed charges,
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA [1000108],AETNA [100010801],,,76.8,,128.75,9.77024,11406.336,percent of total billed charges,
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA [1000108],AETNA [100010801],,,76.8,,128.75,9.77024,11406.336,percent of total billed charges,
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA [1000108],AETNA [100010801],,,76.8,,128.75,9.77024,11406.336,percent of total billed charges,
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA [1000108],AETNA [100010801],,,76.8,,128.75,9.77024,11406.336,percent of total billed charges,
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,AETNA [1000108],AETNA [100010801],,,76.8,,147.79,9.77024,11406.336,percent of total billed charges,
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,AETNA [1000108],AETNA [100010801],,,76.8,,147.79,9.77024,11406.336,percent of total billed charges,
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.77024,11406.336,percent of total billed charges,
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.77024,11406.336,percent of total billed charges,
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,AETNA [1000108],AETNA [100010801],,,76.8,,179.25,9.77024,11406.336,percent of total billed charges,
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,AETNA [1000108],AETNA [100010801],,,76.8,,3662.77,9.77024,11406.336,percent of total billed charges,
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,AETNA [1000108],AETNA [100010801],,,76.8,,3662.77,9.77024,11406.336,percent of total billed charges,
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,76.8,,2929.48,9.77024,11406.336,percent of total billed charges,
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,AETNA [1000108],AETNA [100010801],,,76.8,,6290.63,9.77024,11406.336,percent of total billed charges,
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,AETNA [1000108],AETNA [100010801],,,76.8,,9823.71,9.77024,11406.336,percent of total billed charges,
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,AETNA [1000108],AETNA [100010801],,,76.8,,8041.47,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,13473.73824,percent of total billed charges,
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,AETNA [1000108],AETNA [100010801],,,76.8,,10955.79,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,13473.73824,percent of total billed charges,
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,AETNA [1000108],AETNA [100010801],,,76.8,,10955.79,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,AETNA [1000108],AETNA [100010801],,,76.8,,8472.05,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,AETNA [1000108],AETNA [100010801],,,76.8,,13473.74,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,399.86,13473.73824,percent of total billed charges,
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,76.8,,11406.34,399.86,11406.336,percent of total billed charges,
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,76.8,,11406.34,399.86,11406.336,percent of total billed charges,
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA [1000108],AETNA [100010801],,,76.8,,10836.02,399.86,11406.336,percent of total billed charges,
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,76.8,,2053.2,399.86,11406.336,percent of total billed charges,
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,399.86,11406.336,percent of total billed charges,
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,399.86,11406.336,percent of total billed charges,
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,196.493625,28414.1568,percent of total billed charges,
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,196.493625,28414.1568,percent of total billed charges,
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,76.8,,2658.16,196.493625,28414.1568,percent of total billed charges,
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,AETNA [1000108],AETNA [100010801],,,76.8,,28414.16,196.493625,28414.1568,percent of total billed charges,
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,196.493625,28414.1568,percent of total billed charges,
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,196.493625,28414.1568,percent of total billed charges,
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,AETNA [1000108],AETNA [100010801],,,76.8,,3743.35,196.493625,28414.1568,percent of total billed charges,
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,AETNA [1000108],AETNA [100010801],,,76.8,,3770.5,196.493625,28414.1568,percent of total billed charges,
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,AETNA [1000108],AETNA [100010801],,,76.8,,25295.55,196.493625,28414.1568,percent of total billed charges,
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,196.493625,28414.1568,percent of total billed charges,
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,196.493625,28414.1568,percent of total billed charges,
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,39.298725,2053.20192,percent of total billed charges,
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,AETNA [1000108],AETNA [100010801],,,76.8,,1974.33,39.298725,2053.20192,percent of total billed charges,
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,39.298725,2053.20192,percent of total billed charges,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,76.8,,2053.2,39.298725,2053.20192,percent of total billed charges,
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,76.8,,313.69,39.298725,2053.20192,percent of total billed charges,
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,76.8,,134.44,39.298725,2053.20192,percent of total billed charges,
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,AETNA [1000108],AETNA [100010801],,,76.8,,1957.88,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,AETNA [1000108],AETNA [100010801],,,76.8,,1957.88,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,39.298725,2053.20192,percent of total billed charges,
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA [1000108],AETNA [100010801],,,76.8,,4595.74,399.86,9410.2272,percent of total billed charges,
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,AETNA [1000108],AETNA [100010801],,,76.8,,6486.19,399.86,9410.2272,percent of total billed charges,
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA [1000108],AETNA [100010801],,,76.8,,4015.57,399.86,9410.2272,percent of total billed charges,
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,399.86,9410.2272,percent of total billed charges,
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,399.86,9410.2272,percent of total billed charges,
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,9410.2272,percent of total billed charges,
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA [1000108],AETNA [100010801],,,76.8,,4289.36,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA [1000108],AETNA [100010801],,,76.8,,4289.36,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA [1000108],AETNA [100010801],,,76.8,,4289.36,399.86,9410.2272,percent of total billed charges,
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,9410.2272,percent of total billed charges,
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,9410.2272,percent of total billed charges,
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,AETNA [1000108],AETNA [100010801],,,76.8,,7870.37,399.86,9410.2272,percent of total billed charges,
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA [1000108],AETNA [100010801],,,76.8,,4015.57,399.86,9410.2272,percent of total billed charges,
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA [1000108],AETNA [100010801],,,76.8,,4015.57,399.86,9410.2272,percent of total billed charges,
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,AETNA [1000108],AETNA [100010801],,,76.8,,6381.89,399.86,6381.888,percent of total billed charges,
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,AETNA [1000108],AETNA [100010801],,,76.8,,34094.34,399.86,42246.08608,percent of total billed charges,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA [1000108],AETNA [100010801],,,76.8,,12724.19,399.86,12724.19328,percent of total billed charges,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA [1000108],AETNA [100010801],,,76.8,,19961.09,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,AETNA [1000108],AETNA [100010801],,,76.8,,15281.64,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,AETNA [1000108],AETNA [100010801],,,76.8,,15968.87,399.86,24381.0432,percent of total billed charges,
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,AETNA [1000108],AETNA [100010801],,,76.8,,16753.06,399.86,24381.0432,percent of total billed charges,
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,AETNA [1000108],AETNA [100010801],,,76.8,,15968.87,399.86,24381.0432,percent of total billed charges,
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,399.86,24381.0432,percent of total billed charges,
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,24381.0432,percent of total billed charges,
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,24381.0432,percent of total billed charges,
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,AETNA [1000108],AETNA [100010801],,,76.8,,21301.33,399.86,24381.0432,percent of total billed charges,
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,AETNA [1000108],AETNA [100010801],,,76.8,,15601.01,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,AETNA [1000108],AETNA [100010801],,,76.8,,24381.04,399.86,24381.0432,percent of total billed charges,
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,AETNA [1000108],AETNA [100010801],,,76.8,,21957.2,399.86,24381.0432,percent of total billed charges,
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA [1000108],AETNA [100010801],,,76.8,,19961.09,399.86,24381.0432,percent of total billed charges,
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,24381.0432,percent of total billed charges,
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA [1000108],AETNA [100010801],,,76.8,,19961.09,399.86,24381.0432,percent of total billed charges,
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,AETNA [1000108],AETNA [100010801],,,76.8,,19390.77,399.86,24381.0432,percent of total billed charges,
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,24381.0432,percent of total billed charges,
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,AETNA [1000108],AETNA [100010801],,,76.8,,18726.35,399.86,23086.3872,percent of total billed charges,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,AETNA [1000108],AETNA [100010801],,,76.8,,15683.71,399.86,23086.3872,percent of total billed charges,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,AETNA [1000108],AETNA [100010801],,,76.8,,23086.39,399.86,23086.3872,percent of total billed charges,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,AETNA [1000108],AETNA [100010801],,,76.8,,23086.39,399.86,23086.3872,percent of total billed charges,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,AETNA [1000108],AETNA [100010801],,,76.8,,21779.07,399.86,23086.3872,percent of total billed charges,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,AETNA [1000108],AETNA [100010801],,,76.8,,11965.25,399.86,23086.3872,percent of total billed charges,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA [1000108],AETNA [100010801],,,76.8,,1848.14,399.86,23086.3872,percent of total billed charges,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA [1000108],AETNA [100010801],,,76.8,,1848.14,399.86,23086.3872,percent of total billed charges,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA [1000108],AETNA [100010801],,,76.8,,1848.14,399.86,23086.3872,percent of total billed charges,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA [1000108],AETNA [100010801],,,76.8,,1848.14,399.86,23086.3872,percent of total billed charges,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,AETNA [1000108],AETNA [100010801],,,76.8,,15583.91,399.86,23086.3872,percent of total billed charges,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,76.8,,582.57,170.294475,582.5664,percent of total billed charges,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,,,,24.890315,416.02,other,272 with C codes
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,AETNA [1000108],AETNA [100010801],,,,,,24.890315,416.02,other,272 with C codes
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,AETNA [1000108],AETNA [100010801],,,,,,24.890315,416.02,other,272 with C codes
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,AETNA [1000108],AETNA [100010801],,,,,,24.890315,416.02,other,272 with C codes
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,AETNA [1000108],AETNA [100010801],,,,,,399.86,1487.02215,other,272 with C codes
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,AETNA [1000108],AETNA [100010801],,,76.8,,1562.11,399.86,1724.0184,percent of total billed charges,
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,AETNA [1000108],AETNA [100010801],,,76.8,,1340.16,267.439885,1479.062,percent of total billed charges,
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,AETNA [1000108],AETNA [100010801],,,76.8,,2331.65,399.86,2573.3136,percent of total billed charges,
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,AETNA [1000108],AETNA [100010801],,,76.8,,264.19,77.228,836,percent of total billed charges,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,AETNA [1000108],AETNA [100010801],,,76.8,,921.95,0.71,921.95328,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-10,NDC,outpatient,1,UN,7.54,5.278,AETNA [1000108],AETNA [100010801],,,76.8,,5.79,1.69273,416.02,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-55,NDC,outpatient,1,UN,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,1.69273,416.02,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-51,NDC,outpatient,1,UN,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,1.69273,416.02,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-60,NDC,outpatient,1,UN,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,1.69273,416.02,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-00,NDC,outpatient,1,UN,7.54,5.278,AETNA [1000108],AETNA [100010801],,,76.8,,5.79,1.69273,416.02,percent of total billed charges,
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,AETNA [1000108],AETNA [100010801],,,76.8,,836.84,1.4,836.83584,percent of total billed charges,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,AETNA [1000108],AETNA [100010801],JW,,76.8,,264.87,3.39,416.02,percent of total billed charges,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,AETNA [1000108],AETNA [100010801],,,76.8,,277.16,3.39,416.02,percent of total billed charges,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,AETNA [1000108],AETNA [100010801],,,76.8,,277.16,3.39,416.02,percent of total billed charges,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,AETNA [1000108],AETNA [100010801],JW,,76.8,,264.87,3.39,416.02,percent of total billed charges,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,AETNA [1000108],AETNA [100010801],,,76.8,,213.67,0.31,416.02,percent of total billed charges,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,AETNA [1000108],AETNA [100010801],,,76.8,,77.11,0.31,416.02,percent of total billed charges,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,AETNA [1000108],AETNA [100010801],,,76.8,,77.11,0.31,416.02,percent of total billed charges,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,AETNA [1000108],AETNA [100010801],,,76.8,,1148.18,1.36,1148.18304,percent of total billed charges,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,AETNA [1000108],AETNA [100010801],,,76.8,,1148.18,1.36,1148.18304,percent of total billed charges,
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA [1000108],AETNA [100010801],,,76.8,,5136.8,399.86,5136.79872,percent of total billed charges,
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA [1000108],AETNA [100010801],,,76.8,,5136.8,399.86,5136.79872,percent of total billed charges,
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA [1000108],AETNA [100010801],,,76.8,,5136.8,399.86,5136.79872,percent of total billed charges,
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,AETNA [1000108],AETNA [100010801],,,76.8,,4420.78,182.24,5164.04736,percent of total billed charges,
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,AETNA [1000108],AETNA [100010801],,,76.8,,5164.05,182.24,5164.04736,percent of total billed charges,
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,AETNA [1000108],AETNA [100010801],,,76.8,,5164.05,182.24,5164.04736,percent of total billed charges,
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,AETNA [1000108],AETNA [100010801],,,76.8,,1939.25,399.86,24858.15552,percent of total billed charges,
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,AETNA [1000108],AETNA [100010801],,,76.8,,1939.25,399.86,24858.15552,percent of total billed charges,
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,AETNA [1000108],AETNA [100010801],,,76.8,,7541.25,399.86,24858.15552,percent of total billed charges,
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,AETNA [1000108],AETNA [100010801],,,76.8,,2009.58,399.86,24858.15552,percent of total billed charges,
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,AETNA [1000108],AETNA [100010801],,,76.8,,12471.06,399.86,24858.15552,percent of total billed charges,
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,AETNA [1000108],AETNA [100010801],,,76.8,,7981.47,399.86,24858.15552,percent of total billed charges,
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,AETNA [1000108],AETNA [100010801],,,76.8,,21155.77,399.86,24858.15552,percent of total billed charges,
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,AETNA [1000108],AETNA [100010801],,,76.8,,20265.47,399.86,24858.15552,percent of total billed charges,
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,AETNA [1000108],AETNA [100010801],,,76.8,,24858.16,399.86,24858.15552,percent of total billed charges,
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,AETNA [1000108],AETNA [100010801],,,76.8,,3613.27,399.86,24858.15552,percent of total billed charges,
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,AETNA [1000108],AETNA [100010801],,,76.8,,9353.31,399.86,41430.25152,percent of total billed charges,
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,AETNA [1000108],AETNA [100010801],,,76.8,,7960.2,399.86,41430.25152,percent of total billed charges,
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,AETNA [1000108],AETNA [100010801],,,76.8,,17247.12,399.86,41430.25152,percent of total billed charges,
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,AETNA [1000108],AETNA [100010801],,,76.8,,41430.25,399.86,41430.25152,percent of total billed charges,
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,AETNA [1000108],AETNA [100010801],,,76.8,,5164.09,177.26,5164.08576,percent of total billed charges,
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,AETNA [1000108],AETNA [100010801],,,76.8,,4965.07,177.26,5164.08576,percent of total billed charges,
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,AETNA [1000108],AETNA [100010801],,,76.8,,2294.75,18.39,18739.8144,percent of total billed charges,
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,AETNA [1000108],AETNA [100010801],,,76.8,,3569.98,18.39,18739.8144,percent of total billed charges,
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,AETNA [1000108],AETNA [100010801],,,76.8,,7138.07,18.39,18739.8144,percent of total billed charges,
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,AETNA [1000108],AETNA [100010801],,,76.8,,18739.81,18.39,18739.8144,percent of total billed charges,
SARILUMAB 200 MG/1.14ML SC SOAJ,RX-143091,CDM,C9399,HCPCS,636,RC,00024-5922-01,NDC,outpatient,1.14,ML,5813.71,4069.597,AETNA [1000108],AETNA [100010801],,,76.8,,4464.93,399.86,4927.700596,percent of total billed charges,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,AETNA [1000108],AETNA [100010801],,,76.8,,1865.42,18.2,1865.41824,percent of total billed charges,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,AETNA [1000108],AETNA [100010801],,,76.8,,1865.42,18.2,1865.41824,percent of total billed charges,
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,AETNA [1000108],AETNA [100010801],,,76.8,,25024.51,399.86,25024.512,percent of total billed charges,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26025.216,percent of total billed charges,
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26793.51305,percent of total billed charges,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26025.216,percent of total billed charges,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26025.216,percent of total billed charges,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26793.51305,percent of total billed charges,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26025.216,percent of total billed charges,
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,19.95,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,AETNA [1000108],AETNA [100010801],,,76.8,,165.12,19.95,416.02,percent of total billed charges,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,19.95,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,AETNA [1000108],AETNA [100010801],,,76.8,,165.12,19.95,416.02,percent of total billed charges,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,19.95,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,AETNA [1000108],AETNA [100010801],,,76.8,,165.12,19.95,416.02,percent of total billed charges,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,1592,percent of total billed charges,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,AETNA [1000108],AETNA [100010801],,,76.8,,1322.5,386.589,2141,percent of total billed charges,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,AETNA [1000108],AETNA [100010801],,,76.8,,155.14,45.349,1592,percent of total billed charges,
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,AETNA [1000108],AETNA [100010801],,,76.8,,86.78,25.3685,416.02,percent of total billed charges,
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,AETNA [1000108],AETNA [100010801],,,76.8,,94.46,12.01,416.02,percent of total billed charges,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,AETNA [1000108],AETNA [100010801],,,76.8,,77.57,22.6745,6652,percent of total billed charges,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,AETNA [1000108],AETNA [100010801],,,76.8,,77.57,22.6745,6652,percent of total billed charges,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,AETNA [1000108],AETNA [100010801],,,76.8,,1107.46,104.83,6652,percent of total billed charges,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,AETNA [1000108],AETNA [100010801],,,76.8,,7964.16,399.86,7964.16,percent of total billed charges,
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,AETNA [1000108],AETNA [100010801],,,76.8,,7964.16,399.86,7964.16,percent of total billed charges,
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,AETNA [1000108],AETNA [100010801],,,76.8,,5398.27,399.86,7964.16,percent of total billed charges,
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,
HC Inter Devc Remote 30d,PX-48000092,CDM,G2066,HCPCS,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,AETNA [1000108],AETNA [100010801],,,76.8,,2936.5,43.27,2936.50176,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,AETNA [1000108],AETNA [100010801],,,76.8,,41.34,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,AETNA [1000108],AETNA [100010801],,,76.8,,41.34,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.04,416.02,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,AETNA [1000108],AETNA [100010801],,,76.8,,213.88,0.57,416.02,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,AETNA [1000108],AETNA [100010801],,,76.8,,213.88,0.57,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,AETNA [1000108],AETNA [100010801],,,76.8,,8.81,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,AETNA [1000108],AETNA [100010801],,,76.8,,14.7,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.02,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,AETNA [1000108],AETNA [100010801],,,76.8,,7116.76,336.23,7116.76416,percent of total billed charges,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,AETNA [1000108],AETNA [100010801],,,76.8,,7116.76,336.23,7116.76416,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.12,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.12,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.12,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,AETNA [1000108],AETNA [100010801],,,76.8,,631.25,0.4,631.24992,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,AETNA [1000108],AETNA [100010801],,,76.8,,70.53,0.4,631.24992,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,AETNA [1000108],AETNA [100010801],,,76.8,,84.26,0.4,631.24992,percent of total billed charges,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,AETNA [1000108],AETNA [100010801],,,76.8,,18.95,0.4,631.24992,percent of total billed charges,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,AETNA [1000108],AETNA [100010801],,,76.8,,18.95,0.4,631.24992,percent of total billed charges,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,AETNA [1000108],AETNA [100010801],,,76.8,,473.66,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,AETNA [1000108],AETNA [100010801],,,76.8,,960.94,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,AETNA [1000108],AETNA [100010801],,,76.8,,473.66,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,AETNA [1000108],AETNA [100010801],,,76.8,,389.28,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,AETNA [1000108],AETNA [100010801],,,76.8,,960.94,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,AETNA [1000108],AETNA [100010801],,,76.8,,389.28,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,AETNA [1000108],AETNA [100010801],,,76.8,,473.66,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,AETNA [1000108],AETNA [100010801],,,76.8,,473.66,0.73,960.94464,percent of total billed charges,
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,AETNA [1000108],AETNA [100010801],,,76.8,,64.35,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,AETNA [1000108],AETNA [100010801],,,76.8,,44.21,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,AETNA [1000108],AETNA [100010801],,,76.8,,44.21,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,AETNA [1000108],AETNA [100010801],,,76.8,,32.64,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,AETNA [1000108],AETNA [100010801],,,76.8,,44.21,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,AETNA [1000108],AETNA [100010801],,,76.8,,44.21,0.73,960.94464,percent of total billed charges,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,AETNA [1000108],AETNA [100010801],,,76.8,,27.63,1.61,416.02,percent of total billed charges,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,AETNA [1000108],AETNA [100010801],,,76.8,,27.63,1.61,416.02,percent of total billed charges,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,AETNA [1000108],AETNA [100010801],,,76.8,,15801.65,215.38,15801.64608,percent of total billed charges,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,AETNA [1000108],AETNA [100010801],,,76.8,,2257,215.38,15801.64608,percent of total billed charges,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,AETNA [1000108],AETNA [100010801],,,76.8,,2044.29,194.92,2044.28544,percent of total billed charges,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,AETNA [1000108],AETNA [100010801],,,76.8,,1270.71,5.51,1270.70976,percent of total billed charges,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,AETNA [1000108],AETNA [100010801],,,76.8,,1123.43,4.88,1606.272,percent of total billed charges,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,AETNA [1000108],AETNA [100010801],,,76.8,,1123.43,4.88,1606.272,percent of total billed charges,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,AETNA [1000108],AETNA [100010801],,,76.8,,1606.27,4.88,1606.272,percent of total billed charges,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,AETNA [1000108],AETNA [100010801],,,76.8,,433.55,2.98,4260,percent of total billed charges,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,AETNA [1000108],AETNA [100010801],,,76.8,,433.55,2.98,4260,percent of total billed charges,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,AETNA [1000108],AETNA [100010801],,,76.8,,13.52,0.77,416.02,percent of total billed charges,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,AETNA [1000108],AETNA [100010801],,,76.8,,13.52,0.77,416.02,percent of total billed charges,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,AETNA [1000108],AETNA [100010801],,,76.8,,29.6,4.51,416.02,percent of total billed charges,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,AETNA [1000108],AETNA [100010801],,,76.8,,29.6,4.51,416.02,percent of total billed charges,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,AETNA [1000108],AETNA [100010801],,,76.8,,46.89,4.51,416.02,percent of total billed charges,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,AETNA [1000108],AETNA [100010801],,,76.8,,46.89,4.51,416.02,percent of total billed charges,
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,AETNA [1000108],AETNA [100010801],,,76.8,,168.17,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,AETNA [1000108],AETNA [100010801],,,76.8,,7.23,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,AETNA [1000108],AETNA [100010801],,,76.8,,2.75,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,AETNA [1000108],AETNA [100010801],,,76.8,,2.75,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,AETNA [1000108],AETNA [100010801],,,76.8,,7.23,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,AETNA [1000108],AETNA [100010801],,,76.8,,12.71,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,AETNA [1000108],AETNA [100010801],,,76.8,,12.71,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,AETNA [1000108],AETNA [100010801],,,76.8,,42.57,0.46,416.02,percent of total billed charges,
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,AETNA [1000108],AETNA [100010801],,,76.8,,119.21,34.84689,416.02,percent of total billed charges,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,AETNA [1000108],AETNA [100010801],,,76.8,,331.58,11.13,416.02,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,AETNA [1000108],AETNA [100010801],,,76.8,,974.33,23.33,974.33088,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,AETNA [1000108],AETNA [100010801],,,76.8,,252.63,23.33,974.33088,percent of total billed charges,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,AETNA [1000108],AETNA [100010801],,,76.8,,8.16,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,AETNA [1000108],AETNA [100010801],,,76.8,,6.62,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,AETNA [1000108],AETNA [100010801],,,76.8,,6.62,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,AETNA [1000108],AETNA [100010801],,,76.8,,8.16,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,AETNA [1000108],AETNA [100010801],,,76.8,,12.7,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,AETNA [1000108],AETNA [100010801],,,76.8,,34.74,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,AETNA [1000108],AETNA [100010801],,,76.8,,25.01,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,AETNA [1000108],AETNA [100010801],,,76.8,,10.37,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,AETNA [1000108],AETNA [100010801],,,76.8,,25.01,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,AETNA [1000108],AETNA [100010801],,,76.8,,6.62,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,AETNA [1000108],AETNA [100010801],,,76.8,,6.62,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.78,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,AETNA [1000108],AETNA [100010801],,,76.8,,64.6,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,AETNA [1000108],AETNA [100010801],,,76.8,,19.1,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,AETNA [1000108],AETNA [100010801],,,76.8,,19.1,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,AETNA [1000108],AETNA [100010801],,,76.8,,33.42,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,AETNA [1000108],AETNA [100010801],,,76.8,,22.83,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,AETNA [1000108],AETNA [100010801],,,76.8,,16.2,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,AETNA [1000108],AETNA [100010801],,,76.8,,5.48,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,AETNA [1000108],AETNA [100010801],,,76.8,,16.2,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,AETNA [1000108],AETNA [100010801],,,76.8,,21.66,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,AETNA [1000108],AETNA [100010801],,,76.8,,21.66,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,AETNA [1000108],AETNA [100010801],,,76.8,,27.79,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,AETNA [1000108],AETNA [100010801],,,76.8,,13.86,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,AETNA [1000108],AETNA [100010801],,,76.8,,25.8,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,AETNA [1000108],AETNA [100010801],,,76.8,,25.8,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,AETNA [1000108],AETNA [100010801],,,76.8,,13.86,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.600685,416.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,AETNA [1000108],AETNA [100010801],,,76.8,,64.83,0.82,416.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,AETNA [1000108],AETNA [100010801],,,76.8,,10.86,0.82,416.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,0.82,416.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,AETNA [1000108],AETNA [100010801],,,76.8,,24.27,0.82,416.02,percent of total billed charges,
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,AETNA [1000108],AETNA [100010801],,,76.8,,107.04,0.46,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,AETNA [1000108],AETNA [100010801],,,76.8,,11.3,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,AETNA [1000108],AETNA [100010801],,,76.8,,11.13,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,AETNA [1000108],AETNA [100010801],,,76.8,,11.3,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,AETNA [1000108],AETNA [100010801],,,76.8,,11.13,2.732165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,AETNA [1000108],AETNA [100010801],,,76.8,,9.32,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,AETNA [1000108],AETNA [100010801],,,76.8,,18.73,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,AETNA [1000108],AETNA [100010801],,,76.8,,18.73,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,AETNA [1000108],AETNA [100010801],,,76.8,,35.42,1.834165,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,AETNA [1000108],AETNA [100010801],,,76.8,,75.79,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,AETNA [1000108],AETNA [100010801],,,76.8,,75.79,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,AETNA [1000108],AETNA [100010801],,,76.8,,93.87,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,AETNA [1000108],AETNA [100010801],,,76.8,,187.74,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,AETNA [1000108],AETNA [100010801],,,76.8,,75.79,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,AETNA [1000108],AETNA [100010801],,,76.8,,93.87,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,AETNA [1000108],AETNA [100010801],,,76.8,,75.79,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,AETNA [1000108],AETNA [100010801],,,76.8,,187.74,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,AETNA [1000108],AETNA [100010801],,,76.8,,32.81,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,AETNA [1000108],AETNA [100010801],,,76.8,,14.83,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,AETNA [1000108],AETNA [100010801],,,76.8,,14.83,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,AETNA [1000108],AETNA [100010801],,,76.8,,23.62,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,AETNA [1000108],AETNA [100010801],,,76.8,,23.62,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,AETNA [1000108],AETNA [100010801],,,76.8,,67.26,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,AETNA [1000108],AETNA [100010801],,,76.8,,67.26,0.09,416.02,percent of total billed charges,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,AETNA [1000108],AETNA [100010801],,,76.8,,610.05,174.58,1359.95136,percent of total billed charges,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,AETNA [1000108],AETNA [100010801],,,76.8,,1150.36,174.58,1359.95136,percent of total billed charges,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,AETNA [1000108],AETNA [100010801],,,76.8,,1359.95,174.58,1359.95136,percent of total billed charges,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,AETNA [1000108],AETNA [100010801],,,76.8,,250.99,40.38,416.02,percent of total billed charges,
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,AETNA [1000108],AETNA [100010801],,,76.8,,1346.66,50.93,4488.66816,percent of total billed charges,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,AETNA [1000108],AETNA [100010801],,,76.8,,4488.67,50.93,4488.66816,percent of total billed charges,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,9.23144,416.02,percent of total billed charges,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,AETNA [1000108],AETNA [100010801],,,76.8,,265.45,9.23144,416.02,percent of total billed charges,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,9.23144,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,AETNA [1000108],AETNA [100010801],,,76.8,,75.06,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,AETNA [1000108],AETNA [100010801],,,76.8,,87.56,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,AETNA [1000108],AETNA [100010801],,,76.8,,79.09,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,AETNA [1000108],AETNA [100010801],,,76.8,,87.56,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,AETNA [1000108],AETNA [100010801],,,76.8,,79.09,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,AETNA [1000108],AETNA [100010801],,,76.8,,75.06,16.21,416.02,percent of total billed charges,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,AETNA [1000108],AETNA [100010801],,,76.8,,697.87,15.67,697.86624,percent of total billed charges,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,AETNA [1000108],AETNA [100010801],,,76.8,,697.87,15.67,697.86624,percent of total billed charges,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,AETNA [1000108],AETNA [100010801],,,76.8,,457.41,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,AETNA [1000108],AETNA [100010801],,,76.8,,457.41,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,AETNA [1000108],AETNA [100010801],,,76.8,,875.48,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,AETNA [1000108],AETNA [100010801],,,76.8,,875.48,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,AETNA [1000108],AETNA [100010801],,,76.8,,1623.55,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,AETNA [1000108],AETNA [100010801],,,76.8,,1623.55,20.17,1623.552,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,AETNA [1000108],AETNA [100010801],,,76.8,,236.84,0.17,416.02,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,AETNA [1000108],AETNA [100010801],,,76.8,,226.18,0.17,416.02,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,AETNA [1000108],AETNA [100010801],,,76.8,,145.5,0.17,416.02,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,AETNA [1000108],AETNA [100010801],,,76.8,,236.84,0.17,416.02,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,AETNA [1000108],AETNA [100010801],,,76.8,,226.18,0.17,416.02,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,AETNA [1000108],AETNA [100010801],,,76.8,,1343.88,6.15,1343.87712,percent of total billed charges,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,AETNA [1000108],AETNA [100010801],,,76.8,,40.83,4.03,416.02,percent of total billed charges,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,AETNA [1000108],AETNA [100010801],,,76.8,,40.83,4.03,416.02,percent of total billed charges,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,AETNA [1000108],AETNA [100010801],,,76.8,,22.99,4.06,416.02,percent of total billed charges,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,AETNA [1000108],AETNA [100010801],,,76.8,,22.99,4.06,416.02,percent of total billed charges,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,AETNA [1000108],AETNA [100010801],,,76.8,,12645.76,60.43,12645.75744,percent of total billed charges,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,AETNA [1000108],AETNA [100010801],,,76.8,,12645.76,60.43,12645.75744,percent of total billed charges,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,AETNA [1000108],AETNA [100010801],,,76.8,,28.06,0.04,416.02,percent of total billed charges,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,AETNA [1000108],AETNA [100010801],,,76.8,,28.06,0.04,416.02,percent of total billed charges,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],,,76.8,,28.71,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],,,76.8,,28.71,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,AETNA [1000108],AETNA [100010801],,,76.8,,41,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],JW,,76.8,,28.71,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],JW,,76.8,,28.71,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,AETNA [1000108],AETNA [100010801],,,76.8,,41,0.08,416.02,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,AETNA [1000108],AETNA [100010801],,,76.8,,2155.45,399.86,2155.44576,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,AETNA [1000108],AETNA [100010801],,,76.8,,1684.39,399.86,2155.44576,percent of total billed charges,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,AETNA [1000108],AETNA [100010801],,,76.8,,13.03,2.68951,416.02,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,AETNA [1000108],AETNA [100010801],,,76.8,,81.96,2.68951,416.02,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,AETNA [1000108],AETNA [100010801],,,76.8,,9.2,2.68951,416.02,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,AETNA [1000108],AETNA [100010801],,,76.8,,214.63,4.2921885,416.02,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,AETNA [1000108],AETNA [100010801],,,76.8,,225.36,4.2921885,416.02,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,AETNA [1000108],AETNA [100010801],,,76.8,,225.36,4.2921885,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,AETNA [1000108],AETNA [100010801],,,76.8,,15.05,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,AETNA [1000108],AETNA [100010801],,,76.8,,8.33,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,AETNA [1000108],AETNA [100010801],,,76.8,,6.01,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,AETNA [1000108],AETNA [100010801],,,76.8,,8.53,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,AETNA [1000108],AETNA [100010801],,,76.8,,6.01,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,AETNA [1000108],AETNA [100010801],,,76.8,,15.05,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,AETNA [1000108],AETNA [100010801],,,76.8,,7.46,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,AETNA [1000108],AETNA [100010801],,,76.8,,7.35,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,AETNA [1000108],AETNA [100010801],,,76.8,,14.92,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,AETNA [1000108],AETNA [100010801],,,76.8,,7.35,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,AETNA [1000108],AETNA [100010801],,,76.8,,13.74,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,AETNA [1000108],AETNA [100010801],,,76.8,,13.03,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,AETNA [1000108],AETNA [100010801],,,76.8,,13.03,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,AETNA [1000108],AETNA [100010801],,,76.8,,9.83,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,AETNA [1000108],AETNA [100010801],,,76.8,,9.83,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,AETNA [1000108],AETNA [100010801],,,76.8,,4.22,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,AETNA [1000108],AETNA [100010801],,,76.8,,4.22,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.01,416.02,percent of total billed charges,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,AETNA [1000108],AETNA [100010801],,,76.8,,15.64,0.01,416.02,percent of total billed charges,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,AETNA [1000108],AETNA [100010801],,,76.8,,15.64,0.01,416.02,percent of total billed charges,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,AETNA [1000108],AETNA [100010801],,,76.8,,21.47,3.08,416.02,percent of total billed charges,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,AETNA [1000108],AETNA [100010801],,,76.8,,21.47,3.08,416.02,percent of total billed charges,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,AETNA [1000108],AETNA [100010801],,,76.8,,32.82,1.22,416.02,percent of total billed charges,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,AETNA [1000108],AETNA [100010801],JW,,76.8,,20.54,1.22,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA [1000108],AETNA [100010801],,,76.8,,4.49,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,AETNA [1000108],AETNA [100010801],,,76.8,,31.41,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,AETNA [1000108],AETNA [100010801],,,76.8,,31.41,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,AETNA [1000108],AETNA [100010801],,,76.8,,14.39,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,AETNA [1000108],AETNA [100010801],,,76.8,,14.39,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA [1000108],AETNA [100010801],,,76.8,,4.49,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA [1000108],AETNA [100010801],,,76.8,,4.49,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,AETNA [1000108],AETNA [100010801],,,76.8,,25.27,0.74534,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,AETNA [1000108],AETNA [100010801],,,76.8,,13.8,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,AETNA [1000108],AETNA [100010801],,,76.8,,9.22,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,AETNA [1000108],AETNA [100010801],,,76.8,,18,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,AETNA [1000108],AETNA [100010801],,,76.8,,9.22,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,AETNA [1000108],AETNA [100010801],,,76.8,,24.74,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,AETNA [1000108],AETNA [100010801],,,76.8,,37.58,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,AETNA [1000108],AETNA [100010801],,,76.8,,26.35,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,AETNA [1000108],AETNA [100010801],,,76.8,,9.22,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,AETNA [1000108],AETNA [100010801],,,76.8,,18,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,AETNA [1000108],AETNA [100010801],,,76.8,,13.8,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,AETNA [1000108],AETNA [100010801],,,76.8,,9.22,1.22,416.02,percent of total billed charges,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,AETNA [1000108],AETNA [100010801],,,76.8,,113.15,3.679555,416.02,percent of total billed charges,
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,AETNA [1000108],AETNA [100010801],,,76.8,,35.44,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,AETNA [1000108],AETNA [100010801],,,76.8,,31.43,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,AETNA [1000108],AETNA [100010801],,,76.8,,12.59,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,AETNA [1000108],AETNA [100010801],,,76.8,,63.01,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,AETNA [1000108],AETNA [100010801],,,76.8,,23.3,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,AETNA [1000108],AETNA [100010801],,,76.8,,31.43,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,AETNA [1000108],AETNA [100010801],,,76.8,,12.59,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,AETNA [1000108],AETNA [100010801],,,76.8,,23.3,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,AETNA [1000108],AETNA [100010801],,,76.8,,63.01,3.679555,416.02,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,AETNA [1000108],AETNA [100010801],,,76.8,,500.98,7.54,500.98176,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,AETNA [1000108],AETNA [100010801],,,76.8,,13.82,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,AETNA [1000108],AETNA [100010801],,,76.8,,13.82,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,AETNA [1000108],AETNA [100010801],,,76.8,,6.94,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,AETNA [1000108],AETNA [100010801],,,76.8,,14.38,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,AETNA [1000108],AETNA [100010801],,,76.8,,5.33,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,AETNA [1000108],AETNA [100010801],,,76.8,,5.33,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,AETNA [1000108],AETNA [100010801],,,76.8,,13.82,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,AETNA [1000108],AETNA [100010801],,,76.8,,13.82,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,AETNA [1000108],AETNA [100010801],,,76.8,,14.38,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,AETNA [1000108],AETNA [100010801],,,76.8,,6.94,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,AETNA [1000108],AETNA [100010801],,,76.8,,3.32,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,AETNA [1000108],AETNA [100010801],,,76.8,,4.86,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,AETNA [1000108],AETNA [100010801],,,76.8,,3.32,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,AETNA [1000108],AETNA [100010801],,,76.8,,4.86,0.44,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,AETNA [1000108],AETNA [100010801],,,76.8,,9.6,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,AETNA [1000108],AETNA [100010801],,,76.8,,7.37,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,AETNA [1000108],AETNA [100010801],,,76.8,,9.6,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,AETNA [1000108],AETNA [100010801],,,76.8,,16.62,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,AETNA [1000108],AETNA [100010801],,,76.8,,16.62,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,AETNA [1000108],AETNA [100010801],,,76.8,,9.6,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,AETNA [1000108],AETNA [100010801],,,76.8,,9.6,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,AETNA [1000108],AETNA [100010801],,,76.8,,7.37,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,AETNA [1000108],AETNA [100010801],,,76.8,,16.62,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,AETNA [1000108],AETNA [100010801],,,76.8,,16.62,1.88,416.02,percent of total billed charges,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,AETNA [1000108],AETNA [100010801],,,76.8,,131.14,6.96,416.02,percent of total billed charges,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,AETNA [1000108],AETNA [100010801],,,76.8,,110.53,6.96,416.02,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,AETNA [1000108],AETNA [100010801],,,76.8,,20.54,1.65,416.02,percent of total billed charges,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,AETNA [1000108],AETNA [100010801],,,76.8,,619.45,3.89,619.45344,percent of total billed charges,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,AETNA [1000108],AETNA [100010801],,,76.8,,619.45,3.89,619.45344,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,AETNA [1000108],AETNA [100010801],,,76.8,,619.45,3.89,619.45344,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,AETNA [1000108],AETNA [100010801],,,76.8,,619.45,3.89,619.45344,percent of total billed charges,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,AETNA [1000108],AETNA [100010801],,,76.8,,18.06,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,AETNA [1000108],AETNA [100010801],,,76.8,,10.65,1.66,416.02,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,AETNA [1000108],AETNA [100010801],,,76.8,,1248.58,92.48,1248.58368,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,AETNA [1000108],AETNA [100010801],,,76.8,,1248.58,92.48,1248.58368,percent of total billed charges,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,AETNA [1000108],AETNA [100010801],,,76.8,,34.73,10.15189,416.02,percent of total billed charges,
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,AETNA [1000108],AETNA [100010801],,,76.8,,309.47,10.15189,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,AETNA [1000108],AETNA [100010801],,,76.8,,10.74,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,AETNA [1000108],AETNA [100010801],,,76.8,,10.74,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,AETNA [1000108],AETNA [100010801],,,76.8,,37.07,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,AETNA [1000108],AETNA [100010801],,,76.8,,37.07,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,AETNA [1000108],AETNA [100010801],,,76.8,,49.71,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,AETNA [1000108],AETNA [100010801],JW,,76.8,,37.42,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,AETNA [1000108],AETNA [100010801],JW,,76.8,,37.42,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,AETNA [1000108],AETNA [100010801],,,76.8,,49.71,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,AETNA [1000108],AETNA [100010801],,,76.8,,23.74,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,AETNA [1000108],AETNA [100010801],,,76.8,,23.74,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,AETNA [1000108],AETNA [100010801],,,76.8,,26.3,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,AETNA [1000108],AETNA [100010801],,,76.8,,26.3,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,AETNA [1000108],AETNA [100010801],,,76.8,,26.3,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.02,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,AETNA [1000108],AETNA [100010801],,,76.8,,26.3,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.02,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.02,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.02,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,AETNA [1000108],AETNA [100010801],,,76.8,,29.72,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,AETNA [1000108],AETNA [100010801],,,76.8,,29.72,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],JW,,76.8,,17.43,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],JW,,76.8,,17.43,2.59,416.02,percent of total billed charges,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,AETNA [1000108],AETNA [100010801],,,76.8,,19.65,5.74271,416.02,percent of total billed charges,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,AETNA [1000108],AETNA [100010801],,,76.8,,33.73,5.74271,416.02,percent of total billed charges,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,AETNA [1000108],AETNA [100010801],,,76.8,,33.73,5.74271,416.02,percent of total billed charges,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,AETNA [1000108],AETNA [100010801],,,76.8,,20.58,1.86,416.02,percent of total billed charges,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,AETNA [1000108],AETNA [100010801],,,76.8,,20.58,1.86,416.02,percent of total billed charges,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,AETNA [1000108],AETNA [100010801],,,76.8,,32.79,1.86,416.02,percent of total billed charges,
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,AETNA [1000108],AETNA [100010801],,,76.8,,35.59,10.40333,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,AETNA [1000108],AETNA [100010801],,,76.8,,11.5,3.01,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,AETNA [1000108],AETNA [100010801],,,76.8,,10.54,3.01,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,AETNA [1000108],AETNA [100010801],,,76.8,,11.5,3.01,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,AETNA [1000108],AETNA [100010801],,,76.8,,12.03,3.01,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,AETNA [1000108],AETNA [100010801],,,76.8,,10.54,3.01,416.02,percent of total billed charges,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,AETNA [1000108],AETNA [100010801],,,76.8,,274.09,16.61749,416.02,percent of total billed charges,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,AETNA [1000108],AETNA [100010801],,,76.8,,56.85,16.61749,416.02,percent of total billed charges,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,AETNA [1000108],AETNA [100010801],,,76.8,,274.09,16.61749,416.02,percent of total billed charges,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,AETNA [1000108],AETNA [100010801],,,76.8,,50.52,0.04,416.02,percent of total billed charges,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,AETNA [1000108],AETNA [100010801],,,76.8,,1958.58,14.7,4668.927562,percent of total billed charges,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,AETNA [1000108],AETNA [100010801],,,76.8,,154.75,0.03,416.02,percent of total billed charges,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,AETNA [1000108],AETNA [100010801],,,76.8,,154.82,0.03,416.02,percent of total billed charges,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,AETNA [1000108],AETNA [100010801],,,76.8,,44.23,0.03,416.02,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,AETNA [1000108],AETNA [100010801],JW,,76.8,,263.16,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,AETNA [1000108],AETNA [100010801],,,76.8,,275.44,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,AETNA [1000108],AETNA [100010801],JW,,76.8,,324.5,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,AETNA [1000108],AETNA [100010801],JW,,76.8,,243.68,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,AETNA [1000108],AETNA [100010801],,,76.8,,336.79,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,AETNA [1000108],AETNA [100010801],,,76.8,,255.97,1.35,1059.84,percent of total billed charges,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,AETNA [1000108],AETNA [100010801],,,76.8,,1059.84,1.35,1059.84,percent of total billed charges,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,AETNA [1000108],AETNA [100010801],,,76.8,,173.68,1.35,1059.84,percent of total billed charges,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,AETNA [1000108],AETNA [100010801],,,76.8,,1020.53,1.35,1059.84,percent of total billed charges,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,AETNA [1000108],AETNA [100010801],,,76.8,,478.42,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,AETNA [1000108],AETNA [100010801],,,76.8,,478.42,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,AETNA [1000108],AETNA [100010801],,,76.8,,217.66,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,AETNA [1000108],AETNA [100010801],,,76.8,,350.85,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,AETNA [1000108],AETNA [100010801],,,76.8,,217.66,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,AETNA [1000108],AETNA [100010801],,,76.8,,350.85,6.88,478.41792,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,AETNA [1000108],AETNA [100010801],,,76.8,,275.44,0.46,416.02,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,AETNA [1000108],AETNA [100010801],JW,,76.8,,263.16,0.46,416.02,percent of total billed charges,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,AETNA [1000108],AETNA [100010801],,,76.8,,257.57,1.63,416.02,percent of total billed charges,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,AETNA [1000108],AETNA [100010801],,,76.8,,35.59,6.78,416.02,percent of total billed charges,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,AETNA [1000108],AETNA [100010801],,,76.8,,35.59,6.78,416.02,percent of total billed charges,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,AETNA [1000108],AETNA [100010801],,,76.8,,6805.34,24.19,6805.34016,percent of total billed charges,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,AETNA [1000108],AETNA [100010801],,,76.8,,3570.67,24.19,6805.34016,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1030,HCPCS,636,RC,00009-3073-03,NDC,outpatient,1,ML,22.62,15.834,AETNA [1000108],AETNA [100010801],,,76.8,,17.37,5.07819,416.02,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-01,NDC,outpatient,1,ML,25.95,18.165,AETNA [1000108],AETNA [100010801],,,76.8,,19.93,5.82353,416.02,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-05,NDC,outpatient,1,ML,25.94,18.158,AETNA [1000108],AETNA [100010801],,,76.8,,19.92,5.82353,416.02,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,00009-3475-03,NDC,outpatient,1,ML,34.96,24.472,AETNA [1000108],AETNA [100010801],,,76.8,,26.85,5.82353,416.02,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.03,416.02,percent of total billed charges,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,AETNA [1000108],AETNA [100010801],,,76.8,,2.83,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,AETNA [1000108],AETNA [100010801],,,76.8,,2.83,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,AETNA [1000108],AETNA [100010801],,,76.8,,4.69,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,AETNA [1000108],AETNA [100010801],,,76.8,,5.37,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,AETNA [1000108],AETNA [100010801],,,76.8,,4.69,0.11,416.02,percent of total billed charges,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,AETNA [1000108],AETNA [100010801],,,76.8,,137.85,40.295505,416.02,percent of total billed charges,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,AETNA [1000108],AETNA [100010801],,,76.8,,169.7,40.295505,416.02,percent of total billed charges,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,AETNA [1000108],AETNA [100010801],,,76.8,,137.85,40.295505,416.02,percent of total billed charges,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,AETNA [1000108],AETNA [100010801],,,76.8,,137.43,10.29108,416.02,percent of total billed charges,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,AETNA [1000108],AETNA [100010801],,,76.8,,35.21,10.29108,416.02,percent of total billed charges,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,AETNA [1000108],AETNA [100010801],,,76.8,,126.28,10.29108,416.02,percent of total billed charges,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,AETNA [1000108],AETNA [100010801],,,76.8,,11.23,3.28219,416.02,percent of total billed charges,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,AETNA [1000108],AETNA [100010801],,,76.8,,11.23,3.28219,416.02,percent of total billed charges,
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,AETNA [1000108],AETNA [100010801],,,76.8,,345.13,3.28219,416.02,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,AETNA [1000108],AETNA [100010801],,,76.8,,9367.91,399.86,9367.9104,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,AETNA [1000108],AETNA [100010801],,,76.8,,4.47,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,AETNA [1000108],AETNA [100010801],,,76.8,,4.47,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.44,416.02,percent of total billed charges,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-03,NDC,outpatient,10,ML,44.91,31.437,AETNA [1000108],AETNA [100010801],,,76.8,,34.49,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-01,NDC,outpatient,10,ML,44.91,31.437,AETNA [1000108],AETNA [100010801],,,76.8,,34.49,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00409-2634-25,NDC,outpatient,10,ML,71.61,50.127,AETNA [1000108],AETNA [100010801],,,76.8,,55,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-03,NDC,outpatient,1,ML,11.43,8.001,AETNA [1000108],AETNA [100010801],,,76.8,,8.78,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-96,NDC,outpatient,0.5,ML,12.4,8.68,AETNA [1000108],AETNA [100010801],,,76.8,,9.52,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-31,NDC,outpatient,1,ML,11.43,8.001,AETNA [1000108],AETNA [100010801],,,76.8,,8.78,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-01,NDC,outpatient,1,ML,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-06,NDC,outpatient,0.5,ML,12.4,8.68,AETNA [1000108],AETNA [100010801],,,76.8,,9.52,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-11,NDC,outpatient,1,ML,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-01,NDC,outpatient,1,ML,11.17,7.819,AETNA [1000108],AETNA [100010801],,,76.8,,8.58,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-25,NDC,outpatient,1,ML,11.17,7.819,AETNA [1000108],AETNA [100010801],,,76.8,,8.58,2.507665,416.02,percent of total billed charges,
CONC DILAUDID 10 MG/ML PCA,RX-4080160,CDM,J1170,HCPCS,636,RC,99999-0000-95,NDC,outpatient,50,ML,267.65,187.355,AETNA [1000108],AETNA [100010801],,,76.8,,205.56,2.507665,416.02,percent of total billed charges,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,AETNA [1000108],AETNA [100010801],,,76.8,,442.11,87.49,442.10688,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.74534,416.02,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,AETNA [1000108],AETNA [100010801],,,76.8,,107.21,31.3402,416.02,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,AETNA [1000108],AETNA [100010801],,,76.8,,1422.76,399.86,1422.7584,percent of total billed charges,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,AETNA [1000108],AETNA [100010801],,,76.8,,667.94,9.763505,945.2928,percent of total billed charges,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,AETNA [1000108],AETNA [100010801],,,76.8,,33.4,9.763505,945.2928,percent of total billed charges,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,AETNA [1000108],AETNA [100010801],,,76.8,,945.29,9.763505,945.2928,percent of total billed charges,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,AETNA [1000108],AETNA [100010801],,,76.8,,671.38,9.763505,945.2928,percent of total billed charges,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,AETNA [1000108],AETNA [100010801],,,76.8,,58.21,3.78,416.02,percent of total billed charges,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,AETNA [1000108],AETNA [100010801],,,76.8,,58.21,3.78,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,AETNA [1000108],AETNA [100010801],,,76.8,,29.38,4.15774,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,AETNA [1000108],AETNA [100010801],,,76.8,,40.49,4.15774,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,AETNA [1000108],AETNA [100010801],,,76.8,,40.49,4.15774,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,AETNA [1000108],AETNA [100010801],,,76.8,,55.86,4.15774,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,AETNA [1000108],AETNA [100010801],,,76.8,,55.86,4.15774,416.02,percent of total billed charges,
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,AETNA [1000108],AETNA [100010801],,,76.8,,18.81,4.15774,416.02,percent of total billed charges,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,4.15774,416.02,percent of total billed charges,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,AETNA [1000108],AETNA [100010801],,,76.8,,21.19,4.15774,416.02,percent of total billed charges,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,4.15774,416.02,percent of total billed charges,
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,AETNA [1000108],AETNA [100010801],,,76.8,,31.94,0.7,416.02,percent of total billed charges,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,AETNA [1000108],AETNA [100010801],,,76.8,,38.78,0.7,416.02,percent of total billed charges,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,AETNA [1000108],AETNA [100010801],,,76.8,,37.07,0.7,416.02,percent of total billed charges,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,AETNA [1000108],AETNA [100010801],,,76.8,,38.78,0.7,416.02,percent of total billed charges,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,AETNA [1000108],AETNA [100010801],,,76.8,,10.11,0.7,416.02,percent of total billed charges,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,AETNA [1000108],AETNA [100010801],,,76.8,,10.11,0.7,416.02,percent of total billed charges,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,AETNA [1000108],AETNA [100010801],,,76.8,,16.83,0.7,416.02,percent of total billed charges,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,AETNA [1000108],AETNA [100010801],,,76.8,,13826.66,224.63,13826.65728,percent of total billed charges,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,AETNA [1000108],AETNA [100010801],,,76.8,,200.1,15.86,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,AETNA [1000108],AETNA [100010801],,,76.8,,99.19,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,AETNA [1000108],AETNA [100010801],,,76.8,,97.67,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,AETNA [1000108],AETNA [100010801],,,76.8,,104.21,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,AETNA [1000108],AETNA [100010801],,,76.8,,99.19,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,AETNA [1000108],AETNA [100010801],,,76.8,,77.37,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,AETNA [1000108],AETNA [100010801],,,76.8,,77.37,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,AETNA [1000108],AETNA [100010801],,,76.8,,104.21,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,AETNA [1000108],AETNA [100010801],,,76.8,,85.77,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,AETNA [1000108],AETNA [100010801],,,76.8,,97.67,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,AETNA [1000108],AETNA [100010801],,,76.8,,104.21,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,AETNA [1000108],AETNA [100010801],,,76.8,,97.67,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,AETNA [1000108],AETNA [100010801],,,76.8,,77.37,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,AETNA [1000108],AETNA [100010801],,,76.8,,104.21,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,AETNA [1000108],AETNA [100010801],,,76.8,,77.37,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,AETNA [1000108],AETNA [100010801],,,76.8,,99.19,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,AETNA [1000108],AETNA [100010801],,,76.8,,85.77,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,AETNA [1000108],AETNA [100010801],,,76.8,,97.67,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,AETNA [1000108],AETNA [100010801],,,76.8,,99.19,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,10.42,416.02,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,AETNA [1000108],AETNA [100010801],,,76.8,,181.27,52.988735,416.02,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,AETNA [1000108],AETNA [100010801],,,76.8,,181.27,52.988735,416.02,percent of total billed charges,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,AETNA [1000108],AETNA [100010801],,,76.8,,1162.26,339.74932,1162.26048,percent of total billed charges,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,AETNA [1000108],AETNA [100010801],,,76.8,,1903.33,1.1,1903.32672,percent of total billed charges,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,AETNA [1000108],AETNA [100010801],,,76.8,,27.67,2.61,416.02,percent of total billed charges,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,AETNA [1000108],AETNA [100010801],,,76.8,,27.29,2.61,416.02,percent of total billed charges,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,AETNA [1000108],AETNA [100010801],,,76.8,,27.29,2.61,416.02,percent of total billed charges,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,AETNA [1000108],AETNA [100010801],,,76.8,,27.33,2.61,416.02,percent of total billed charges,
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,AETNA [1000108],AETNA [100010801],,,76.8,,18.02,2.61,416.02,percent of total billed charges,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,AETNA [1000108],AETNA [100010801],,,76.8,,1290.93,7.3781655,1590,percent of total billed charges,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,AETNA [1000108],AETNA [100010801],,,76.8,,1547.36,7.3781655,1590,percent of total billed charges,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,AETNA [1000108],AETNA [100010801],,,76.8,,1056.72,0.14,1056.72192,percent of total billed charges,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,AETNA [1000108],AETNA [100010801],,,76.8,,1056.72,0.14,1056.72192,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,AETNA [1000108],AETNA [100010801],,,76.8,,8270.99,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,AETNA [1000108],AETNA [100010801],,,76.8,,2067.75,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,AETNA [1000108],AETNA [100010801],,,76.8,,2067.75,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,AETNA [1000108],AETNA [100010801],,,76.8,,4135.5,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,AETNA [1000108],AETNA [100010801],,,76.8,,2067.75,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,AETNA [1000108],AETNA [100010801],,,76.8,,2067.75,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,AETNA [1000108],AETNA [100010801],,,76.8,,8270.99,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,AETNA [1000108],AETNA [100010801],,,76.8,,324.71,48.47,416.02,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,AETNA [1000108],AETNA [100010801],,,76.8,,324.71,48.47,416.02,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,AETNA [1000108],AETNA [100010801],,,76.8,,6450.62,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,AETNA [1000108],AETNA [100010801],,,76.8,,1612.65,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,AETNA [1000108],AETNA [100010801],,,76.8,,1612.65,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,AETNA [1000108],AETNA [100010801],,,76.8,,3225.31,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,AETNA [1000108],AETNA [100010801],,,76.8,,1612.65,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,AETNA [1000108],AETNA [100010801],,,76.8,,3225.31,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,AETNA [1000108],AETNA [100010801],,,76.8,,6450.62,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,AETNA [1000108],AETNA [100010801],,,76.8,,1612.65,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,AETNA [1000108],AETNA [100010801],,,76.8,,717.7,77.77,1531.4,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,AETNA [1000108],AETNA [100010801],,,76.8,,887.01,77.77,1531.4,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,AETNA [1000108],AETNA [100010801],,,76.8,,443.5,77.77,1531.4,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,AETNA [1000108],AETNA [100010801],,,76.8,,1447.32,44.12,1447.31904,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,AETNA [1000108],AETNA [100010801],,,76.8,,1447.32,44.12,1447.31904,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,AETNA [1000108],AETNA [100010801],,,76.8,,4187.64,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,AETNA [1000108],AETNA [100010801],,,76.8,,6281.46,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,AETNA [1000108],AETNA [100010801],,,76.8,,6281.46,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,AETNA [1000108],AETNA [100010801],,,76.8,,4187.64,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,AETNA [1000108],AETNA [100010801],,,76.8,,127.39,36.41,416.02,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,AETNA [1000108],AETNA [100010801],,,76.8,,1632.15,48.52,3264.3072,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,AETNA [1000108],AETNA [100010801],,,76.8,,1632.15,48.52,3264.3072,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,AETNA [1000108],AETNA [100010801],,,76.8,,3264.31,48.52,3264.3072,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,AETNA [1000108],AETNA [100010801],,,76.8,,1632.15,48.52,3264.3072,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,AETNA [1000108],AETNA [100010801],,,76.8,,3264.31,48.52,3264.3072,percent of total billed charges,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,AETNA [1000108],AETNA [100010801],,,76.8,,19.39,1.23924,416.02,percent of total billed charges,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,AETNA [1000108],AETNA [100010801],,,76.8,,7.59,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,AETNA [1000108],AETNA [100010801],,,76.8,,7.59,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,AETNA [1000108],AETNA [100010801],,,76.8,,78.81,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,AETNA [1000108],AETNA [100010801],,,76.8,,78.81,1.23924,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,AETNA [1000108],AETNA [100010801],,,76.8,,13.16,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,AETNA [1000108],AETNA [100010801],,,76.8,,4.37,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,AETNA [1000108],AETNA [100010801],,,76.8,,4.37,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,AETNA [1000108],AETNA [100010801],,,76.8,,3.36,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,AETNA [1000108],AETNA [100010801],,,76.8,,3.36,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,AETNA [1000108],AETNA [100010801],,,76.8,,5.81,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,AETNA [1000108],AETNA [100010801],,,76.8,,13.16,0.51,416.02,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,AETNA [1000108],AETNA [100010801],,,76.8,,579.46,90.641875,579.456,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,AETNA [1000108],AETNA [100010801],,,76.8,,310.08,90.641875,579.456,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,AETNA [1000108],AETNA [100010801],,,76.8,,310.08,90.641875,579.456,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,AETNA [1000108],AETNA [100010801],,,76.8,,310.08,90.641875,579.456,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,AETNA [1000108],AETNA [100010801],,,76.8,,468.95,101.41,468.94848,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,AETNA [1000108],AETNA [100010801],,,76.8,,468.95,101.41,468.94848,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,AETNA [1000108],AETNA [100010801],,,76.8,,468.93,101.41,468.94848,percent of total billed charges,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,AETNA [1000108],AETNA [100010801],,,76.8,,8.8,0.28,416.02,percent of total billed charges,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,AETNA [1000108],AETNA [100010801],,,76.8,,8.8,0.28,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,AETNA [1000108],AETNA [100010801],,,76.8,,12.01,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,AETNA [1000108],AETNA [100010801],,,76.8,,5.54,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,AETNA [1000108],AETNA [100010801],,,76.8,,5.54,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,AETNA [1000108],AETNA [100010801],,,76.8,,2.89,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,AETNA [1000108],AETNA [100010801],,,76.8,,12.01,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,AETNA [1000108],AETNA [100010801],,,76.8,,2.89,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.02,416.02,percent of total billed charges,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.02,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,AETNA [1000108],AETNA [100010801],,,76.8,,12.28,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,AETNA [1000108],AETNA [100010801],,,76.8,,16.74,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,AETNA [1000108],AETNA [100010801],,,76.8,,14.37,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,AETNA [1000108],AETNA [100010801],,,76.8,,15.25,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,AETNA [1000108],AETNA [100010801],,,76.8,,15.25,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,AETNA [1000108],AETNA [100010801],,,76.8,,12.28,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,AETNA [1000108],AETNA [100010801],,,76.8,,14.37,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,AETNA [1000108],AETNA [100010801],,,76.8,,2.94,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,AETNA [1000108],AETNA [100010801],,,76.8,,2.94,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,AETNA [1000108],AETNA [100010801],,,76.8,,10.07,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,AETNA [1000108],AETNA [100010801],,,76.8,,12.91,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,AETNA [1000108],AETNA [100010801],,,76.8,,3.87,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,AETNA [1000108],AETNA [100010801],,,76.8,,16.74,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,AETNA [1000108],AETNA [100010801],,,76.8,,16.72,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,AETNA [1000108],AETNA [100010801],,,76.8,,16.72,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,AETNA [1000108],AETNA [100010801],,,76.8,,10.07,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,AETNA [1000108],AETNA [100010801],,,76.8,,26,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,AETNA [1000108],AETNA [100010801],,,76.8,,26,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,AETNA [1000108],AETNA [100010801],,,76.8,,4.88,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,AETNA [1000108],AETNA [100010801],,,76.8,,4.88,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,AETNA [1000108],AETNA [100010801],,,76.8,,2.56,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,AETNA [1000108],AETNA [100010801],,,76.8,,2.56,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,AETNA [1000108],AETNA [100010801],,,76.8,,49.03,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,AETNA [1000108],AETNA [100010801],,,76.8,,49.03,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,AETNA [1000108],AETNA [100010801],,,76.8,,59.28,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,AETNA [1000108],AETNA [100010801],,,76.8,,92.23,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,AETNA [1000108],AETNA [100010801],,,76.8,,70.22,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,AETNA [1000108],AETNA [100010801],,,76.8,,25.96,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,AETNA [1000108],AETNA [100010801],,,76.8,,17.56,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,AETNA [1000108],AETNA [100010801],,,76.8,,16.9,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,AETNA [1000108],AETNA [100010801],,,76.8,,12.39,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,AETNA [1000108],AETNA [100010801],,,76.8,,32.82,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,AETNA [1000108],AETNA [100010801],,,76.8,,23.35,0.22,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,AETNA [1000108],AETNA [100010801],,,76.8,,30.76,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,AETNA [1000108],AETNA [100010801],,,76.8,,41.01,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,AETNA [1000108],AETNA [100010801],,,76.8,,51.26,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,AETNA [1000108],AETNA [100010801],,,76.8,,61.52,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,AETNA [1000108],AETNA [100010801],,,76.8,,76.9,0.57,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,AETNA [1000108],AETNA [100010801],,,76.8,,112.24,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,AETNA [1000108],AETNA [100010801],,,76.8,,44.94,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,AETNA [1000108],AETNA [100010801],,,76.8,,44.94,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,AETNA [1000108],AETNA [100010801],,,76.8,,112.24,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,AETNA [1000108],AETNA [100010801],,,76.8,,35.06,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,AETNA [1000108],AETNA [100010801],,,76.8,,35.06,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,AETNA [1000108],AETNA [100010801],,,76.8,,112.24,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,AETNA [1000108],AETNA [100010801],,,76.8,,112.24,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,AETNA [1000108],AETNA [100010801],,,76.8,,16.13,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,AETNA [1000108],AETNA [100010801],,,76.8,,15.94,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,AETNA [1000108],AETNA [100010801],,,76.8,,15.94,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,AETNA [1000108],AETNA [100010801],,,76.8,,16.13,0.92,416.02,percent of total billed charges,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,AETNA [1000108],AETNA [100010801],,,76.8,,1140.12,333.276985,1140.11904,percent of total billed charges,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,AETNA [1000108],AETNA [100010801],,,76.8,,1140.12,333.276985,1140.11904,percent of total billed charges,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,AETNA [1000108],AETNA [100010801],,,76.8,,117.81,13.56878,416.02,percent of total billed charges,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,AETNA [1000108],AETNA [100010801],,,76.8,,237.08,13.56878,416.02,percent of total billed charges,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,AETNA [1000108],AETNA [100010801],,,76.8,,64.27,13.56878,416.02,percent of total billed charges,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,AETNA [1000108],AETNA [100010801],,,76.8,,46.42,13.56878,416.02,percent of total billed charges,
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,AETNA [1000108],AETNA [100010801],,,76.8,,224.1,27.14,416.02,percent of total billed charges,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,AETNA [1000108],AETNA [100010801],,,76.8,,292.04,85.36837,416.02,percent of total billed charges,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,AETNA [1000108],AETNA [100010801],,,76.8,,2399.95,32.22,2399.94624,percent of total billed charges,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,AETNA [1000108],AETNA [100010801],,,76.8,,112.08,17.18,416.02,percent of total billed charges,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,AETNA [1000108],AETNA [100010801],,,76.8,,112.08,17.18,416.02,percent of total billed charges,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,AETNA [1000108],AETNA [100010801],,,76.8,,214.22,0.21,416.02,percent of total billed charges,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,AETNA [1000108],AETNA [100010801],,,76.8,,101.16,0.21,416.02,percent of total billed charges,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,AETNA [1000108],AETNA [100010801],,,76.8,,214.22,0.21,416.02,percent of total billed charges,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,AETNA [1000108],AETNA [100010801],,,76.8,,105.44,0.21,416.02,percent of total billed charges,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,AETNA [1000108],AETNA [100010801],,,76.8,,24.06,3.83,416.02,percent of total billed charges,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,AETNA [1000108],AETNA [100010801],,,76.8,,24.06,3.83,416.02,percent of total billed charges,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,1.834165,416.02,percent of total billed charges,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,1.834165,416.02,percent of total billed charges,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,AETNA [1000108],AETNA [100010801],,,76.8,,327.57,0.19,416.02,percent of total billed charges,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,AETNA [1000108],AETNA [100010801],,,76.8,,258.36,0.19,416.02,percent of total billed charges,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,AETNA [1000108],AETNA [100010801],JW,,76.8,,246.07,0.19,416.02,percent of total billed charges,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,AETNA [1000108],AETNA [100010801],JW,,76.8,,315.28,0.19,416.02,percent of total billed charges,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,AETNA [1000108],AETNA [100010801],,,76.8,,7.98,0.19,416.02,percent of total billed charges,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,AETNA [1000108],AETNA [100010801],,,76.8,,13.15,0.19,416.02,percent of total billed charges,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,AETNA [1000108],AETNA [100010801],,,76.8,,13.15,0.19,416.02,percent of total billed charges,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,AETNA [1000108],AETNA [100010801],,,76.8,,330.98,0.36,416.02,percent of total billed charges,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,AETNA [1000108],AETNA [100010801],JW,,76.8,,318.7,0.36,416.02,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,AETNA [1000108],AETNA [100010801],,,76.8,,1432.34,114.43,1432.33536,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,AETNA [1000108],AETNA [100010801],,,76.8,,1432.34,114.43,1432.33536,percent of total billed charges,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,AETNA [1000108],AETNA [100010801],,,76.8,,1207.54,1,1207.54176,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,AETNA [1000108],AETNA [100010801],,,76.8,,18.61,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,AETNA [1000108],AETNA [100010801],JW,,76.8,,5.53,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,AETNA [1000108],AETNA [100010801],JW,,76.8,,3.95,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,AETNA [1000108],AETNA [100010801],JW,,76.8,,6.32,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,AETNA [1000108],AETNA [100010801],,,76.8,,18.61,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,AETNA [1000108],AETNA [100010801],,,76.8,,17.82,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,AETNA [1000108],AETNA [100010801],JW,,76.8,,6.32,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,AETNA [1000108],AETNA [100010801],JW,,76.8,,7.5,0.02,416.02,percent of total billed charges,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,AETNA [1000108],AETNA [100010801],,,76.8,,15.64,0.02,416.02,percent of total billed charges,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,AETNA [1000108],AETNA [100010801],,,76.8,,15.64,0.02,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,AETNA [1000108],AETNA [100010801],,,76.8,,2.74,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,AETNA [1000108],AETNA [100010801],,,76.8,,7.5,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,AETNA [1000108],AETNA [100010801],,,76.8,,3.69,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,AETNA [1000108],AETNA [100010801],,,76.8,,7.5,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,AETNA [1000108],AETNA [100010801],,,76.8,,3.69,0.55,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,AETNA [1000108],AETNA [100010801],,,76.8,,31.31,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,AETNA [1000108],AETNA [100010801],,,76.8,,27.11,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,AETNA [1000108],AETNA [100010801],,,76.8,,7.66,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,AETNA [1000108],AETNA [100010801],,,76.8,,9.32,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,AETNA [1000108],AETNA [100010801],,,76.8,,12.42,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,AETNA [1000108],AETNA [100010801],,,76.8,,12.42,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,AETNA [1000108],AETNA [100010801],,,76.8,,27.11,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,AETNA [1000108],AETNA [100010801],,,76.8,,14.49,1.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,AETNA [1000108],AETNA [100010801],,,76.8,,6.8,1.24,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,AETNA [1000108],AETNA [100010801],,,76.8,,9.49,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,AETNA [1000108],AETNA [100010801],,,76.8,,11.84,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,AETNA [1000108],AETNA [100010801],,,76.8,,10.91,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,AETNA [1000108],AETNA [100010801],,,76.8,,6.17,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,AETNA [1000108],AETNA [100010801],,,76.8,,6.64,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,AETNA [1000108],AETNA [100010801],,,76.8,,9.49,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,AETNA [1000108],AETNA [100010801],,,76.8,,10.91,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,AETNA [1000108],AETNA [100010801],,,76.8,,6.64,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,AETNA [1000108],AETNA [100010801],,,76.8,,11.84,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,AETNA [1000108],AETNA [100010801],,,76.8,,6.17,0.62,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,AETNA [1000108],AETNA [100010801],,,76.8,,5.53,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,AETNA [1000108],AETNA [100010801],,,76.8,,4.15,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,AETNA [1000108],AETNA [100010801],,,76.8,,6.4,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,AETNA [1000108],AETNA [100010801],,,76.8,,7.1,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,AETNA [1000108],AETNA [100010801],,,76.8,,5.57,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,AETNA [1000108],AETNA [100010801],,,76.8,,2.91,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,AETNA [1000108],AETNA [100010801],,,76.8,,2.81,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,AETNA [1000108],AETNA [100010801],,,76.8,,2.91,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,AETNA [1000108],AETNA [100010801],,,76.8,,7.1,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,AETNA [1000108],AETNA [100010801],,,76.8,,5.53,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,AETNA [1000108],AETNA [100010801],,,76.8,,2.81,0.4,416.02,percent of total billed charges,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,AETNA [1000108],AETNA [100010801],,,76.8,,3654.68,399.86,10964.15232,percent of total billed charges,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,AETNA [1000108],AETNA [100010801],,,76.8,,10964.15,399.86,10964.15232,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,AETNA [1000108],AETNA [100010801],,,76.8,,37.24,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,AETNA [1000108],AETNA [100010801],,,76.8,,49.2,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,AETNA [1000108],AETNA [100010801],,,76.8,,48.86,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,AETNA [1000108],AETNA [100010801],,,76.8,,49.2,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,AETNA [1000108],AETNA [100010801],,,76.8,,48.86,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,AETNA [1000108],AETNA [100010801],,,76.8,,37.24,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,AETNA [1000108],AETNA [100010801],,,76.8,,67.32,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,AETNA [1000108],AETNA [100010801],,,76.8,,67.32,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,AETNA [1000108],AETNA [100010801],,,76.8,,33.14,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,AETNA [1000108],AETNA [100010801],,,76.8,,46.13,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,AETNA [1000108],AETNA [100010801],,,76.8,,46.13,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,AETNA [1000108],AETNA [100010801],,,76.8,,61.16,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,AETNA [1000108],AETNA [100010801],,,76.8,,61.16,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,AETNA [1000108],AETNA [100010801],,,76.8,,4.9,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,AETNA [1000108],AETNA [100010801],,,76.8,,4.9,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,AETNA [1000108],AETNA [100010801],,,76.8,,3.89,0.06,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,AETNA [1000108],AETNA [100010801],,,76.8,,19.4,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,AETNA [1000108],AETNA [100010801],,,76.8,,24.73,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,AETNA [1000108],AETNA [100010801],,,76.8,,24.73,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,AETNA [1000108],AETNA [100010801],,,76.8,,25.91,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,AETNA [1000108],AETNA [100010801],,,76.8,,18.41,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,AETNA [1000108],AETNA [100010801],,,76.8,,35.02,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,AETNA [1000108],AETNA [100010801],,,76.8,,19.4,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,AETNA [1000108],AETNA [100010801],,,76.8,,20.38,0.92,416.02,percent of total billed charges,
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2001,HCPCS,636,RC,00338-0409-03,NDC,outpatient,500,ML,42.7,29.89,AETNA [1000108],AETNA [100010801],,,76.8,,32.79,0.02,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,AETNA [1000108],AETNA [100010801],,,76.8,,76.88,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,AETNA [1000108],AETNA [100010801],,,76.8,,76.88,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,AETNA [1000108],AETNA [100010801],,,76.8,,41,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,AETNA [1000108],AETNA [100010801],,,76.8,,76.88,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,AETNA [1000108],AETNA [100010801],,,76.8,,41,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,AETNA [1000108],AETNA [100010801],,,76.8,,76.88,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,3.08,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,AETNA [1000108],AETNA [100010801],,,76.8,,3.87,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,AETNA [1000108],AETNA [100010801],,,76.8,,3.87,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,AETNA [1000108],AETNA [100010801],,,76.8,,12.33,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,AETNA [1000108],AETNA [100010801],,,76.8,,12.33,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.85,416.02,percent of total billed charges,
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,AETNA [1000108],AETNA [100010801],,,76.8,,97.22,0.85,416.02,percent of total billed charges,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,2.30786,416.02,percent of total billed charges,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,2.30786,416.02,percent of total billed charges,
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,AETNA [1000108],AETNA [100010801],,,76.8,,46.03,2.386435,416.02,percent of total billed charges,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,AETNA [1000108],AETNA [100010801],,,76.8,,8.16,2.386435,416.02,percent of total billed charges,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,AETNA [1000108],AETNA [100010801],,,76.8,,8.16,2.386435,416.02,percent of total billed charges,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,AETNA [1000108],AETNA [100010801],,,76.8,,8.51,2.386435,416.02,percent of total billed charges,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,AETNA [1000108],AETNA [100010801],,,76.8,,8.51,2.386435,416.02,percent of total billed charges,
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,AETNA [1000108],AETNA [100010801],,,76.8,,6255.52,29.75,6255.52128,percent of total billed charges,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,0.35,416.02,percent of total billed charges,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,0.35,416.02,percent of total billed charges,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,AETNA [1000108],AETNA [100010801],,,76.8,,5.72,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,AETNA [1000108],AETNA [100010801],,,76.8,,13.23,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,AETNA [1000108],AETNA [100010801],,,76.8,,37.59,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,AETNA [1000108],AETNA [100010801],,,76.8,,37.59,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,AETNA [1000108],AETNA [100010801],,,76.8,,35.29,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,AETNA [1000108],AETNA [100010801],,,76.8,,35.29,0.35,416.02,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,AETNA [1000108],AETNA [100010801],,,76.8,,68.5,15.18518,416.02,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,AETNA [1000108],AETNA [100010801],,,76.8,,68.5,15.18518,416.02,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,AETNA [1000108],AETNA [100010801],,,76.8,,51.95,15.18518,416.02,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,AETNA [1000108],AETNA [100010801],,,76.8,,51.95,15.18518,416.02,percent of total billed charges,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,AETNA [1000108],AETNA [100010801],,,76.8,,506.22,1.07677,506.21952,percent of total billed charges,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,AETNA [1000108],AETNA [100010801],,,76.8,,295.25,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,AETNA [1000108],AETNA [100010801],,,76.8,,123.16,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,AETNA [1000108],AETNA [100010801],,,76.8,,123.16,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,AETNA [1000108],AETNA [100010801],,,76.8,,590.53,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,AETNA [1000108],AETNA [100010801],,,76.8,,246.32,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,AETNA [1000108],AETNA [100010801],,,76.8,,104.52,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,AETNA [1000108],AETNA [100010801],,,76.8,,246.32,0.29,590.53056,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,AETNA [1000108],AETNA [100010801],,,76.8,,10.33,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,AETNA [1000108],AETNA [100010801],,,76.8,,10.33,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.13,416.02,percent of total billed charges,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,AETNA [1000108],AETNA [100010801],,,76.8,,122.23,0.13,416.02,percent of total billed charges,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,AETNA [1000108],AETNA [100010801],,,76.8,,58.15,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,AETNA [1000108],AETNA [100010801],,,76.8,,3.03,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,AETNA [1000108],AETNA [100010801],,,76.8,,6.2,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,AETNA [1000108],AETNA [100010801],,,76.8,,6.2,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,AETNA [1000108],AETNA [100010801],,,76.8,,3.03,0.13,416.02,percent of total billed charges,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,AETNA [1000108],AETNA [100010801],,,76.8,,59.45,0.18,416.02,percent of total billed charges,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,AETNA [1000108],AETNA [100010801],,,76.8,,59.45,0.18,416.02,percent of total billed charges,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,1.41,416.02,percent of total billed charges,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,1.41,416.02,percent of total billed charges,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,AETNA [1000108],AETNA [100010801],,,76.8,,38.61,1.41,416.02,percent of total billed charges,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,AETNA [1000108],AETNA [100010801],,,76.8,,12.63,1.41,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,AETNA [1000108],AETNA [100010801],,,76.8,,6.94,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,AETNA [1000108],AETNA [100010801],,,76.8,,6.94,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,AETNA [1000108],AETNA [100010801],,,76.8,,8.2,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,AETNA [1000108],AETNA [100010801],,,76.8,,8.2,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,AETNA [1000108],AETNA [100010801],,,76.8,,25.64,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,AETNA [1000108],AETNA [100010801],,,76.8,,88.86,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,AETNA [1000108],AETNA [100010801],,,76.8,,6.54,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,AETNA [1000108],AETNA [100010801],,,76.8,,6.54,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,AETNA [1000108],AETNA [100010801],,,76.8,,7.19,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,AETNA [1000108],AETNA [100010801],,,76.8,,7.19,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,AETNA [1000108],AETNA [100010801],,,76.8,,6.35,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,AETNA [1000108],AETNA [100010801],,,76.8,,6.21,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,AETNA [1000108],AETNA [100010801],,,76.8,,6.35,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,AETNA [1000108],AETNA [100010801],,,76.8,,63.06,10.46,1022.48448,percent of total billed charges,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,AETNA [1000108],AETNA [100010801],,,76.8,,63.06,10.46,1022.48448,percent of total billed charges,
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,AETNA [1000108],AETNA [100010801],,,76.8,,534.11,10.46,1022.48448,percent of total billed charges,
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,AETNA [1000108],AETNA [100010801],,,76.8,,1022.48,10.46,1022.48448,percent of total billed charges,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,AETNA [1000108],AETNA [100010801],,,76.8,,13.66,2.72,416.02,percent of total billed charges,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,AETNA [1000108],AETNA [100010801],,,76.8,,13.66,2.72,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,AETNA [1000108],AETNA [100010801],,,76.8,,48.18,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,AETNA [1000108],AETNA [100010801],JW,,76.8,,35.89,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,AETNA [1000108],AETNA [100010801],JW,,76.8,,30.76,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,AETNA [1000108],AETNA [100010801],,,76.8,,43.05,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,AETNA [1000108],AETNA [100010801],,,76.8,,34.94,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,AETNA [1000108],AETNA [100010801],,,76.8,,44.76,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,AETNA [1000108],AETNA [100010801],JW,,76.8,,32.47,1.3,416.02,percent of total billed charges,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,AETNA [1000108],AETNA [100010801],,,76.8,,39.48,1.3,416.02,percent of total billed charges,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,AETNA [1000108],AETNA [100010801],,,76.8,,39.48,1.3,416.02,percent of total billed charges,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,AETNA [1000108],AETNA [100010801],,,76.8,,32.32,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,AETNA [1000108],AETNA [100010801],,,76.8,,11.86,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,AETNA [1000108],AETNA [100010801],,,76.8,,48.51,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,AETNA [1000108],AETNA [100010801],,,76.8,,10.37,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,AETNA [1000108],AETNA [100010801],,,76.8,,10.37,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,AETNA [1000108],AETNA [100010801],,,76.8,,11.86,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,AETNA [1000108],AETNA [100010801],,,76.8,,48.51,3.03075,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,AETNA [1000108],AETNA [100010801],,,76.8,,13.5,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,AETNA [1000108],AETNA [100010801],,,76.8,,13.5,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,AETNA [1000108],AETNA [100010801],,,76.8,,9.15,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,AETNA [1000108],AETNA [100010801],,,76.8,,9.15,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,AETNA [1000108],AETNA [100010801],,,76.8,,19.33,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,AETNA [1000108],AETNA [100010801],,,76.8,,35.73,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,AETNA [1000108],AETNA [100010801],,,76.8,,35.73,0.86,416.02,percent of total billed charges,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,AETNA [1000108],AETNA [100010801],,,76.8,,2935.67,38.29,2935.67232,percent of total billed charges,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,AETNA [1000108],AETNA [100010801],,,76.8,,1467.84,38.29,2935.67232,percent of total billed charges,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,AETNA [1000108],AETNA [100010801],,,76.8,,2935.67,38.29,2935.67232,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,AETNA [1000108],AETNA [100010801],,,76.8,,88.83,0.92,416.02,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,AETNA [1000108],AETNA [100010801],,,76.8,,47.95,0.92,416.02,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,AETNA [1000108],AETNA [100010801],,,76.8,,47.95,0.92,416.02,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,AETNA [1000108],AETNA [100010801],,,76.8,,158.82,0.92,416.02,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,AETNA [1000108],AETNA [100010801],,,76.8,,59.44,0.92,416.02,percent of total billed charges,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,AETNA [1000108],AETNA [100010801],,,76.8,,14.77,4.317135,416.02,percent of total billed charges,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,AETNA [1000108],AETNA [100010801],,,76.8,,14.77,4.317135,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,AETNA [1000108],AETNA [100010801],,,76.8,,19.42,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,AETNA [1000108],AETNA [100010801],,,76.8,,19.04,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,AETNA [1000108],AETNA [100010801],,,76.8,,18.29,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,AETNA [1000108],AETNA [100010801],,,76.8,,15.13,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,AETNA [1000108],AETNA [100010801],,,76.8,,15.13,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,AETNA [1000108],AETNA [100010801],,,76.8,,7.6,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,AETNA [1000108],AETNA [100010801],,,76.8,,7.6,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.01,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,AETNA [1000108],AETNA [100010801],,,76.8,,39.31,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,AETNA [1000108],AETNA [100010801],,,76.8,,60.56,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,AETNA [1000108],AETNA [100010801],,,76.8,,39.31,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,AETNA [1000108],AETNA [100010801],,,76.8,,60.56,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,AETNA [1000108],AETNA [100010801],,,76.8,,41.5,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,AETNA [1000108],AETNA [100010801],,,76.8,,63.57,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,AETNA [1000108],AETNA [100010801],,,76.8,,41.5,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,AETNA [1000108],AETNA [100010801],,,76.8,,63.57,0.03,416.02,percent of total billed charges,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,0.54,416.02,percent of total billed charges,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,0.54,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,AETNA [1000108],AETNA [100010801],,,76.8,,13.9,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,AETNA [1000108],AETNA [100010801],,,76.8,,4.68,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,AETNA [1000108],AETNA [100010801],,,76.8,,4.68,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,AETNA [1000108],AETNA [100010801],,,76.8,,28.27,8.263845,416.02,percent of total billed charges,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,AETNA [1000108],AETNA [100010801],,,76.8,,35.65,8.263845,416.02,percent of total billed charges,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,AETNA [1000108],AETNA [100010801],,,76.8,,19.28,0.62,416.02,percent of total billed charges,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,AETNA [1000108],AETNA [100010801],,,76.8,,10.23,0.62,416.02,percent of total billed charges,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,AETNA [1000108],AETNA [100010801],,,76.8,,31.27,0.5,416.02,percent of total billed charges,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,AETNA [1000108],AETNA [100010801],,,76.8,,45671.09,399.86,45671.09376,percent of total billed charges,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,AETNA [1000108],AETNA [100010801],,,76.8,,42.75,1.01,416.02,percent of total billed charges,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,AETNA [1000108],AETNA [100010801],,,76.8,,13.77,1.01,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,AETNA [1000108],AETNA [100010801],,,76.8,,23.46,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,AETNA [1000108],AETNA [100010801],,,76.8,,21.47,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,AETNA [1000108],AETNA [100010801],,,76.8,,23.46,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,AETNA [1000108],AETNA [100010801],,,76.8,,7.52,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,AETNA [1000108],AETNA [100010801],,,76.8,,9.91,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,AETNA [1000108],AETNA [100010801],,,76.8,,7.52,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,AETNA [1000108],AETNA [100010801],,,76.8,,19.3,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,AETNA [1000108],AETNA [100010801],,,76.8,,13.56,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,AETNA [1000108],AETNA [100010801],,,76.8,,10.91,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,AETNA [1000108],AETNA [100010801],,,76.8,,6.73,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,AETNA [1000108],AETNA [100010801],,,76.8,,13.56,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,AETNA [1000108],AETNA [100010801],,,76.8,,19.3,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,AETNA [1000108],AETNA [100010801],,,76.8,,6.1,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,AETNA [1000108],AETNA [100010801],,,76.8,,6.1,1.1,416.02,percent of total billed charges,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,AETNA [1000108],AETNA [100010801],,,76.8,,5.95,1.739875,416.02,percent of total billed charges,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,AETNA [1000108],AETNA [100010801],,,76.8,,5.95,1.739875,416.02,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,AETNA [1000108],AETNA [100010801],,,76.8,,119.71,13.89655,416.02,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,AETNA [1000108],AETNA [100010801],,,76.8,,119.71,13.89655,416.02,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,AETNA [1000108],AETNA [100010801],,,76.8,,47.54,13.89655,416.02,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,AETNA [1000108],AETNA [100010801],,,76.8,,47.54,13.89655,416.02,percent of total billed charges,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.74534,416.02,percent of total billed charges,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,AETNA [1000108],AETNA [100010801],,,76.8,,70.58,5.42,416.02,percent of total billed charges,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,AETNA [1000108],AETNA [100010801],,,76.8,,70.58,5.42,416.02,percent of total billed charges,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,AETNA [1000108],AETNA [100010801],,,76.8,,422.75,1.62,422.7456,percent of total billed charges,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,AETNA [1000108],AETNA [100010801],JW,,76.8,,410.46,1.62,422.7456,percent of total billed charges,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,AETNA [1000108],AETNA [100010801],,,76.8,,422.75,1.62,422.7456,percent of total billed charges,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,AETNA [1000108],AETNA [100010801],JW,,76.8,,410.46,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,AETNA [1000108],AETNA [100010801],,,76.8,,39.03,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,AETNA [1000108],AETNA [100010801],,,76.8,,16.85,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,AETNA [1000108],AETNA [100010801],,,76.8,,135.04,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,AETNA [1000108],AETNA [100010801],,,76.8,,16.85,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,AETNA [1000108],AETNA [100010801],,,76.8,,135.04,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,AETNA [1000108],AETNA [100010801],,,76.8,,39.03,1.62,422.7456,percent of total billed charges,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,AETNA [1000108],AETNA [100010801],,,76.8,,15.07,4.40469,416.02,percent of total billed charges,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,AETNA [1000108],AETNA [100010801],,,76.8,,25.26,4.586535,416.02,percent of total billed charges,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,AETNA [1000108],AETNA [100010801],,,76.8,,15.69,4.586535,416.02,percent of total billed charges,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,AETNA [1000108],AETNA [100010801],,,76.8,,18.76,5.484535,1082.90304,percent of total billed charges,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,AETNA [1000108],AETNA [100010801],,,76.8,,18.76,5.484535,1082.90304,percent of total billed charges,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,AETNA [1000108],AETNA [100010801],,,76.8,,1082.9,5.484535,1082.90304,percent of total billed charges,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,AETNA [1000108],AETNA [100010801],,,76.8,,1082.9,5.484535,1082.90304,percent of total billed charges,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,AETNA [1000108],AETNA [100010801],,,76.8,,375.94,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,AETNA [1000108],AETNA [100010801],,,76.8,,115.55,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,AETNA [1000108],AETNA [100010801],,,76.8,,105.51,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,AETNA [1000108],AETNA [100010801],,,76.8,,16.1,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,AETNA [1000108],AETNA [100010801],,,76.8,,16.1,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,AETNA [1000108],AETNA [100010801],,,76.8,,14.68,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,AETNA [1000108],AETNA [100010801],,,76.8,,19.33,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,AETNA [1000108],AETNA [100010801],,,76.8,,29.37,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,AETNA [1000108],AETNA [100010801],,,76.8,,29.37,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,AETNA [1000108],AETNA [100010801],,,76.8,,19.33,0.87,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,AETNA [1000108],AETNA [100010801],,,76.8,,7.66,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,AETNA [1000108],AETNA [100010801],,,76.8,,16.58,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,AETNA [1000108],AETNA [100010801],,,76.8,,16.58,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,AETNA [1000108],AETNA [100010801],,,76.8,,14.18,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,AETNA [1000108],AETNA [100010801],,,76.8,,28.37,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,AETNA [1000108],AETNA [100010801],,,76.8,,7.35,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,AETNA [1000108],AETNA [100010801],,,76.8,,7.35,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,AETNA [1000108],AETNA [100010801],,,76.8,,7.66,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,AETNA [1000108],AETNA [100010801],,,76.8,,33.15,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,AETNA [1000108],AETNA [100010801],,,76.8,,33.15,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,AETNA [1000108],AETNA [100010801],,,76.8,,25.29,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],,,76.8,,14.35,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],,,76.8,,14.35,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,AETNA [1000108],AETNA [100010801],,,76.8,,44.09,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,AETNA [1000108],AETNA [100010801],,,76.8,,15.72,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,AETNA [1000108],AETNA [100010801],,,76.8,,28.37,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,AETNA [1000108],AETNA [100010801],,,76.8,,8.06,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,AETNA [1000108],AETNA [100010801],,,76.8,,15.72,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,AETNA [1000108],AETNA [100010801],,,76.8,,14.18,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,AETNA [1000108],AETNA [100010801],,,76.8,,6.87,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,AETNA [1000108],AETNA [100010801],,,76.8,,7.66,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,AETNA [1000108],AETNA [100010801],,,76.8,,25.29,0.09,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,AETNA [1000108],AETNA [100010801],,,76.8,,22.05,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,AETNA [1000108],AETNA [100010801],,,76.8,,28.87,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,AETNA [1000108],AETNA [100010801],,,76.8,,45.44,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,AETNA [1000108],AETNA [100010801],,,76.8,,45.44,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,AETNA [1000108],AETNA [100010801],,,76.8,,40.66,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,AETNA [1000108],AETNA [100010801],,,76.8,,34.34,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,AETNA [1000108],AETNA [100010801],,,76.8,,28.01,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,AETNA [1000108],AETNA [100010801],,,76.8,,28.01,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,AETNA [1000108],AETNA [100010801],,,76.8,,28.87,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,AETNA [1000108],AETNA [100010801],,,76.8,,26.47,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,AETNA [1000108],AETNA [100010801],,,76.8,,37.58,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,AETNA [1000108],AETNA [100010801],,,76.8,,26.47,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,AETNA [1000108],AETNA [100010801],,,76.8,,40.66,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,AETNA [1000108],AETNA [100010801],,,76.8,,37.58,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.09,416.02,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,AETNA [1000108],AETNA [100010801],,,76.8,,56.38,0.09,416.02,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,AETNA [1000108],AETNA [100010801],,,76.8,,26.86,0.43,416.02,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,AETNA [1000108],AETNA [100010801],,,76.8,,26.86,0.43,416.02,percent of total billed charges,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,AETNA [1000108],AETNA [100010801],,,76.8,,103.39,0.95,416.02,percent of total billed charges,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,AETNA [1000108],AETNA [100010801],,,76.8,,34.42,0.95,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,AETNA [1000108],AETNA [100010801],,,76.8,,13.23,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,AETNA [1000108],AETNA [100010801],,,76.8,,6.97,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,AETNA [1000108],AETNA [100010801],,,76.8,,13.23,0.92943,416.02,percent of total billed charges,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,AETNA [1000108],AETNA [100010801],,,76.8,,1471.6,7.136465,1471.59552,percent of total billed charges,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,AETNA [1000108],AETNA [100010801],,,76.8,,1471.6,7.136465,1471.59552,percent of total billed charges,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,AETNA [1000108],AETNA [100010801],,,76.8,,2360.16,357.36,11800.75008,percent of total billed charges,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,AETNA [1000108],AETNA [100010801],,,76.8,,11800.75,357.36,11800.75008,percent of total billed charges,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,AETNA [1000108],AETNA [100010801],,,76.8,,20.71,2.88,455.8464,percent of total billed charges,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,AETNA [1000108],AETNA [100010801],,,76.8,,23.59,2.88,455.8464,percent of total billed charges,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,AETNA [1000108],AETNA [100010801],,,76.8,,455.85,2.88,455.8464,percent of total billed charges,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,AETNA [1000108],AETNA [100010801],,,76.8,,3005.14,33.71,3005.13792,percent of total billed charges,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,AETNA [1000108],AETNA [100010801],,,76.8,,3005.14,33.71,3005.13792,percent of total billed charges,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,AETNA [1000108],AETNA [100010801],,,76.8,,1769.47,10.7,2359.38048,percent of total billed charges,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,AETNA [1000108],AETNA [100010801],,,76.8,,2359.38,10.7,2359.38048,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,AETNA [1000108],AETNA [100010801],,,76.8,,45.73,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,AETNA [1000108],AETNA [100010801],,,76.8,,15.52,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,AETNA [1000108],AETNA [100010801],,,76.8,,12.08,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,AETNA [1000108],AETNA [100010801],,,76.8,,45.73,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,AETNA [1000108],AETNA [100010801],,,76.8,,12.08,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,AETNA [1000108],AETNA [100010801],,,76.8,,15.79,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,AETNA [1000108],AETNA [100010801],,,76.8,,15.52,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,AETNA [1000108],AETNA [100010801],,,76.8,,15.79,0.06,416.02,percent of total billed charges,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,AETNA [1000108],AETNA [100010801],,,76.8,,2653.84,95.47,5307.61728,percent of total billed charges,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,AETNA [1000108],AETNA [100010801],,,76.8,,5307.62,95.47,5307.61728,percent of total billed charges,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,AETNA [1000108],AETNA [100010801],,,76.8,,3182.53,139.22,12730.14528,percent of total billed charges,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,AETNA [1000108],AETNA [100010801],,,76.8,,12730.15,139.22,12730.14528,percent of total billed charges,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,AETNA [1000108],AETNA [100010801],,,76.8,,27.52,2.12,416.02,percent of total billed charges,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,2.12,416.02,percent of total billed charges,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,AETNA [1000108],AETNA [100010801],,,76.8,,27.52,2.12,416.02,percent of total billed charges,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,2.12,416.02,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-28,NDC,outpatient,1,UN,20.03,14.021,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,4.24,416.02,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-30,NDC,outpatient,1,UN,20.03,14.021,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,4.24,416.02,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2930,HCPCS,636,RC,00009-0698-01,NDC,outpatient,1,UN,79.04,55.328,AETNA [1000108],AETNA [100010801],,,76.8,,60.7,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-22,NDC,outpatient,1,UN,31.87,22.309,AETNA [1000108],AETNA [100010801],,,76.8,,24.48,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-25,NDC,outpatient,1,UN,31.87,22.309,AETNA [1000108],AETNA [100010801],,,76.8,,24.48,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2930,HCPCS,636,RC,00009-0850-01,NDC,outpatient,1,UN,735.77,515.039,AETNA [1000108],AETNA [100010801],,,76.8,,565.07,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2930,HCPCS,636,RC,00009-0758-01,NDC,outpatient,1,UN,87,60.9,AETNA [1000108],AETNA [100010801],,,76.8,,66.82,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ ACT-O-VIAL,RX-4081056,CDM,J2930,HCPCS,636,RC,00009-0018-20,NDC,outpatient,1,UN,235.14,164.598,AETNA [1000108],AETNA [100010801],,,76.8,,180.59,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ ACT-O-VIAL,RX-4081057,CDM,J2930,HCPCS,636,RC,00009-0003-02,NDC,outpatient,1,UN,180.85,126.595,AETNA [1000108],AETNA [100010801],,,76.8,,138.89,5.73,565.07136,percent of total billed charges,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,AETNA [1000108],AETNA [100010801],,,76.8,,556.9,89.15,17236.24704,percent of total billed charges,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,AETNA [1000108],AETNA [100010801],,,76.8,,555.81,89.15,17236.24704,percent of total billed charges,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,AETNA [1000108],AETNA [100010801],,,76.8,,17236.25,89.15,17236.24704,percent of total billed charges,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,AETNA [1000108],AETNA [100010801],,,76.8,,8618.14,89.15,17236.24704,percent of total billed charges,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,AETNA [1000108],AETNA [100010801],,,76.8,,143.32,31.57,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,AETNA [1000108],AETNA [100010801],,,76.8,,7.23,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,AETNA [1000108],AETNA [100010801],,,76.8,,30.76,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,AETNA [1000108],AETNA [100010801],,,76.8,,5.61,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,AETNA [1000108],AETNA [100010801],,,76.8,,5.61,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,AETNA [1000108],AETNA [100010801],,,76.8,,30.76,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,AETNA [1000108],AETNA [100010801],,,76.8,,7.23,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.84,416.02,percent of total billed charges,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,AETNA [1000108],AETNA [100010801],,,76.8,,14884.49,152.7,14884.48512,percent of total billed charges,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,AETNA [1000108],AETNA [100010801],,,76.8,,4.93,1.358225,416.02,percent of total billed charges,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,AETNA [1000108],AETNA [100010801],,,76.8,,4.65,1.358225,416.02,percent of total billed charges,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,AETNA [1000108],AETNA [100010801],,,76.8,,4.65,1.358225,416.02,percent of total billed charges,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,AETNA [1000108],AETNA [100010801],,,76.8,,4.93,1.358225,416.02,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,AETNA [1000108],AETNA [100010801],,,76.8,,82.98,14.63291,416.02,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,AETNA [1000108],AETNA [100010801],,,76.8,,82.98,14.63291,416.02,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,AETNA [1000108],AETNA [100010801],,,76.8,,50.06,14.63291,416.02,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,AETNA [1000108],AETNA [100010801],,,76.8,,50.06,14.63291,416.02,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,AETNA [1000108],AETNA [100010801],,,76.8,,4191.12,399.86,4191.12192,percent of total billed charges,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,AETNA [1000108],AETNA [100010801],,,76.8,,91.9,0.52,416.02,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,AETNA [1000108],AETNA [100010801],JW,,76.8,,555.36,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,AETNA [1000108],AETNA [100010801],JW,,76.8,,168.49,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,AETNA [1000108],AETNA [100010801],JW,,76.8,,394.74,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,AETNA [1000108],AETNA [100010801],,,76.8,,231.7,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,AETNA [1000108],AETNA [100010801],,,76.8,,407.02,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,AETNA [1000108],AETNA [100010801],,,76.8,,180.78,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,AETNA [1000108],AETNA [100010801],JW,,76.8,,219.41,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,AETNA [1000108],AETNA [100010801],JW,,76.8,,152.42,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,AETNA [1000108],AETNA [100010801],,,76.8,,567.65,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,AETNA [1000108],AETNA [100010801],,,76.8,,164.71,3.83,567.65184,percent of total billed charges,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,AETNA [1000108],AETNA [100010801],,,76.8,,153,44.72489,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,AETNA [1000108],AETNA [100010801],,,76.8,,167.36,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,AETNA [1000108],AETNA [100010801],,,76.8,,12.3,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,AETNA [1000108],AETNA [100010801],,,76.8,,10.55,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,AETNA [1000108],AETNA [100010801],,,76.8,,10.55,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,AETNA [1000108],AETNA [100010801],,,76.8,,34.76,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,AETNA [1000108],AETNA [100010801],,,76.8,,46.45,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,AETNA [1000108],AETNA [100010801],,,76.8,,34.76,0.882285,416.02,percent of total billed charges,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,AETNA [1000108],AETNA [100010801],,,76.8,,1092.13,5.91,5460.64128,percent of total billed charges,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,AETNA [1000108],AETNA [100010801],,,76.8,,2730.3,5.91,5460.64128,percent of total billed charges,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,AETNA [1000108],AETNA [100010801],,,76.8,,5460.64,5.91,5460.64128,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,AETNA [1000108],AETNA [100010801],,,76.8,,38.18,0.9,416.02,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,AETNA [1000108],AETNA [100010801],,,76.8,,29.57,0.9,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,AETNA [1000108],AETNA [100010801],,,76.8,,81.44,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,AETNA [1000108],AETNA [100010801],,,76.8,,46.43,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,AETNA [1000108],AETNA [100010801],,,76.8,,46.43,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,AETNA [1000108],AETNA [100010801],,,76.8,,48.95,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,AETNA [1000108],AETNA [100010801],,,76.8,,81.44,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,AETNA [1000108],AETNA [100010801],,,76.8,,48.95,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,AETNA [1000108],AETNA [100010801],,,76.8,,45.8,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,AETNA [1000108],AETNA [100010801],,,76.8,,45.8,5.25,416.02,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,AETNA [1000108],AETNA [100010801],,,76.8,,38.35,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,AETNA [1000108],AETNA [100010801],,,76.8,,27.01,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,AETNA [1000108],AETNA [100010801],,,76.8,,205.06,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,AETNA [1000108],AETNA [100010801],,,76.8,,672.65,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,AETNA [1000108],AETNA [100010801],,,76.8,,157.89,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,AETNA [1000108],AETNA [100010801],,,76.8,,82.44,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,AETNA [1000108],AETNA [100010801],,,76.8,,40.66,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,AETNA [1000108],AETNA [100010801],,,76.8,,56.38,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,AETNA [1000108],AETNA [100010801],,,76.8,,8.59,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,AETNA [1000108],AETNA [100010801],,,76.8,,8.59,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,AETNA [1000108],AETNA [100010801],,,76.8,,280.04,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,AETNA [1000108],AETNA [100010801],,,76.8,,277.69,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,AETNA [1000108],AETNA [100010801],,,76.8,,62.38,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,AETNA [1000108],AETNA [100010801],,,76.8,,39.79,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,AETNA [1000108],AETNA [100010801],,,76.8,,39.79,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,AETNA [1000108],AETNA [100010801],,,76.8,,11.84,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,AETNA [1000108],AETNA [100010801],,,76.8,,11.84,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,AETNA [1000108],AETNA [100010801],,,76.8,,40.14,2.16,672.6528,percent of total billed charges,
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,AETNA [1000108],AETNA [100010801],,,76.8,,18370.38,22.26,18370.38336,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,AETNA [1000108],AETNA [100010801],,,76.8,,63.2,12.41,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,AETNA [1000108],AETNA [100010801],,,76.8,,3.54,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,AETNA [1000108],AETNA [100010801],,,76.8,,3.59,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,AETNA [1000108],AETNA [100010801],,,76.8,,3.54,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,AETNA [1000108],AETNA [100010801],,,76.8,,3.03,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,AETNA [1000108],AETNA [100010801],,,76.8,,3.03,0.88453,416.02,percent of total billed charges,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,AETNA [1000108],AETNA [100010801],,,76.8,,15.49,4.528165,416.02,percent of total billed charges,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,AETNA [1000108],AETNA [100010801],,,76.8,,15.49,4.528165,416.02,percent of total billed charges,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,AETNA [1000108],AETNA [100010801],,,76.8,,8.32,1.15,416.02,percent of total billed charges,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,AETNA [1000108],AETNA [100010801],,,76.8,,4.75,1.15,416.02,percent of total billed charges,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,AETNA [1000108],AETNA [100010801],,,76.8,,8.32,1.15,416.02,percent of total billed charges,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,AETNA [1000108],AETNA [100010801],,,76.8,,4.75,1.15,416.02,percent of total billed charges,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,AETNA [1000108],AETNA [100010801],,,76.8,,1897.88,5.69,1897.8816,percent of total billed charges,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,AETNA [1000108],AETNA [100010801],,,76.8,,75.38,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,AETNA [1000108],AETNA [100010801],,,76.8,,60.65,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,AETNA [1000108],AETNA [100010801],,,76.8,,65.69,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,AETNA [1000108],AETNA [100010801],,,76.8,,65.69,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,AETNA [1000108],AETNA [100010801],,,76.8,,65.69,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,AETNA [1000108],AETNA [100010801],,,76.8,,63.51,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,AETNA [1000108],AETNA [100010801],,,76.8,,60.65,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,AETNA [1000108],AETNA [100010801],,,76.8,,63.51,2.51,416.02,percent of total billed charges,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,AETNA [1000108],AETNA [100010801],,,76.8,,68.7,0.78,416.02,percent of total billed charges,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,AETNA [1000108],AETNA [100010801],,,76.8,,60.22,0.78,416.02,percent of total billed charges,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,AETNA [1000108],AETNA [100010801],,,76.8,,45.43,0.78,416.02,percent of total billed charges,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,AETNA [1000108],AETNA [100010801],,,76.8,,250.31,0.78,416.02,percent of total billed charges,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,AETNA [1000108],AETNA [100010801],,,76.8,,126.6,0.36,416.02,percent of total billed charges,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,AETNA [1000108],AETNA [100010801],,,76.8,,126.6,0.36,416.02,percent of total billed charges,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,AETNA [1000108],AETNA [100010801],,,76.8,,126.6,0.36,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,AETNA [1000108],AETNA [100010801],,,76.8,,23.35,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,AETNA [1000108],AETNA [100010801],,,76.8,,23.35,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,AETNA [1000108],AETNA [100010801],,,76.8,,17.03,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,AETNA [1000108],AETNA [100010801],,,76.8,,27.89,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,AETNA [1000108],AETNA [100010801],,,76.8,,33.65,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,AETNA [1000108],AETNA [100010801],,,76.8,,33.65,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,AETNA [1000108],AETNA [100010801],,,76.8,,25.91,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,AETNA [1000108],AETNA [100010801],,,76.8,,27.89,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,AETNA [1000108],AETNA [100010801],,,76.8,,19,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,AETNA [1000108],AETNA [100010801],,,76.8,,21.96,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,AETNA [1000108],AETNA [100010801],,,76.8,,24.92,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,AETNA [1000108],AETNA [100010801],,,76.8,,24.92,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,AETNA [1000108],AETNA [100010801],,,76.8,,29.38,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,AETNA [1000108],AETNA [100010801],,,76.8,,29.38,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,AETNA [1000108],AETNA [100010801],,,76.8,,5.02,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,AETNA [1000108],AETNA [100010801],,,76.8,,4.19,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,AETNA [1000108],AETNA [100010801],,,76.8,,5.02,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,AETNA [1000108],AETNA [100010801],,,76.8,,4.19,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,AETNA [1000108],AETNA [100010801],,,76.8,,42.55,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.47,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,AETNA [1000108],AETNA [100010801],,,76.8,,20.58,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,AETNA [1000108],AETNA [100010801],,,76.8,,28.35,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,AETNA [1000108],AETNA [100010801],,,76.8,,20.58,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,AETNA [1000108],AETNA [100010801],,,76.8,,29.04,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,AETNA [1000108],AETNA [100010801],,,76.8,,28.87,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,AETNA [1000108],AETNA [100010801],,,76.8,,23.94,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,AETNA [1000108],AETNA [100010801],,,76.8,,23.74,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.1,416.02,percent of total billed charges,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,AETNA [1000108],AETNA [100010801],,,76.8,,29.38,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,AETNA [1000108],AETNA [100010801],,,76.8,,36.21,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,AETNA [1000108],AETNA [100010801],,,76.8,,36.21,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,AETNA [1000108],AETNA [100010801],,,76.8,,96.79,1.51,416.02,percent of total billed charges,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,AETNA [1000108],AETNA [100010801],,,76.8,,96.79,1.51,416.02,percent of total billed charges,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,AETNA [1000108],AETNA [100010801],,,76.8,,203.46,7.43,416.02,percent of total billed charges,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,AETNA [1000108],AETNA [100010801],,,76.8,,203.46,7.43,416.02,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,AETNA [1000108],AETNA [100010801],,,76.8,,23.45,6.47,416.02,percent of total billed charges,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,AETNA [1000108],AETNA [100010801],,,76.8,,140.11,6.47,416.02,percent of total billed charges,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,AETNA [1000108],AETNA [100010801],,,76.8,,97.39,6.47,416.02,percent of total billed charges,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,AETNA [1000108],AETNA [100010801],,,76.8,,10347.43,399.86,10347.43296,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,2.54,416.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,2.54,416.02,percent of total billed charges,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,1.14,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,AETNA [1000108],AETNA [100010801],,,76.8,,17.03,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,AETNA [1000108],AETNA [100010801],,,76.8,,17.62,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,AETNA [1000108],AETNA [100010801],,,76.8,,23.15,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,AETNA [1000108],AETNA [100010801],,,76.8,,23.15,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,AETNA [1000108],AETNA [100010801],,,76.8,,32.79,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,3.62,416.02,percent of total billed charges,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,AETNA [1000108],AETNA [100010801],,,76.8,,89.19,19.23,416.02,percent of total billed charges,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,AETNA [1000108],AETNA [100010801],,,76.8,,89.19,19.23,416.02,percent of total billed charges,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,AETNA [1000108],AETNA [100010801],,,76.8,,25.96,2.39,416.02,percent of total billed charges,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,2.39,416.02,percent of total billed charges,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,2.39,416.02,percent of total billed charges,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,2.39,416.02,percent of total billed charges,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,5.89986,416.02,percent of total billed charges,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,AETNA [1000108],AETNA [100010801],,,76.8,,2321.05,2.568211,4642.0992,percent of total billed charges,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,AETNA [1000108],AETNA [100010801],,,76.8,,4642.1,2.568211,4642.0992,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,AETNA [1000108],AETNA [100010801],,,76.8,,1112.83,1.26,2225.664,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,AETNA [1000108],AETNA [100010801],,,76.8,,2225.66,1.26,2225.664,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,AETNA [1000108],AETNA [100010801],,,76.8,,1398.99,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,AETNA [1000108],AETNA [100010801],,,76.8,,1398.99,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,AETNA [1000108],AETNA [100010801],,,76.8,,2797.98,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,AETNA [1000108],AETNA [100010801],,,76.8,,2797.98,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,AETNA [1000108],AETNA [100010801],,,76.8,,2331.65,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,AETNA [1000108],AETNA [100010801],,,76.8,,2331.65,1.23,3240,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,AETNA [1000108],AETNA [100010801],,,76.8,,4871.24,2.13,24356.18304,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,AETNA [1000108],AETNA [100010801],,,76.8,,4871.24,2.13,24356.18304,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,AETNA [1000108],AETNA [100010801],,,76.8,,9742.48,2.13,24356.18304,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,AETNA [1000108],AETNA [100010801],,,76.8,,9742.48,2.13,24356.18304,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,AETNA [1000108],AETNA [100010801],,,76.8,,24356.18,2.13,24356.18304,percent of total billed charges,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,AETNA [1000108],AETNA [100010801],,,76.8,,1430.78,1.25,2861.568,percent of total billed charges,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,AETNA [1000108],AETNA [100010801],,,76.8,,2861.57,1.25,2861.568,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,AETNA [1000108],AETNA [100010801],,,76.8,,3804.83,3.35,3804.8256,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,AETNA [1000108],AETNA [100010801],,,76.8,,3804.83,3.35,3804.8256,percent of total billed charges,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,AETNA [1000108],AETNA [100010801],,,76.8,,10651.39,1.94,10651.392,percent of total billed charges,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,AETNA [1000108],AETNA [100010801],,,76.8,,786.36,73.22,786.36288,percent of total billed charges,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.536555,416.02,percent of total billed charges,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.536555,416.02,percent of total billed charges,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,AETNA [1000108],AETNA [100010801],,,76.8,,109.71,15.32,416.02,percent of total billed charges,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,AETNA [1000108],AETNA [100010801],,,76.8,,68.56,0.52,416.02,percent of total billed charges,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,AETNA [1000108],AETNA [100010801],,,76.8,,229.09,0.52,416.02,percent of total billed charges,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,AETNA [1000108],AETNA [100010801],,,76.8,,262.1,0.86,416.02,percent of total billed charges,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,AETNA [1000108],AETNA [100010801],,,76.8,,262.1,0.86,416.02,percent of total billed charges,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,AETNA [1000108],AETNA [100010801],,,76.8,,237.88,69.53663,416.02,percent of total billed charges,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,AETNA [1000108],AETNA [100010801],,,76.8,,237.88,69.53663,416.02,percent of total billed charges,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,AETNA [1000108],AETNA [100010801],,,76.8,,10.84,0.370425,416.02,percent of total billed charges,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,AETNA [1000108],AETNA [100010801],,,76.8,,3.37,0.370425,416.02,percent of total billed charges,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.370425,416.02,percent of total billed charges,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.370425,416.02,percent of total billed charges,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,AETNA [1000108],AETNA [100010801],,,76.8,,11.97,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,AETNA [1000108],AETNA [100010801],,,76.8,,6.7,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,AETNA [1000108],AETNA [100010801],,,76.8,,11.97,0.370425,416.02,percent of total billed charges,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,AETNA [1000108],AETNA [100010801],,,76.8,,1.52,0.370425,416.02,percent of total billed charges,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,AETNA [1000108],AETNA [100010801],,,76.8,,33.81,2.5,525.12,percent of total billed charges,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,AETNA [1000108],AETNA [100010801],,,76.8,,15.11,2.5,525.12,percent of total billed charges,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,AETNA [1000108],AETNA [100010801],,,76.8,,26.66,2.5,525.12,percent of total billed charges,
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,AETNA [1000108],AETNA [100010801],,,76.8,,110.32,2.5,525.12,percent of total billed charges,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,AETNA [1000108],AETNA [100010801],,,76.8,,525.12,2.5,525.12,percent of total billed charges,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,AETNA [1000108],AETNA [100010801],,,76.8,,2367.72,7.2,2367.72096,percent of total billed charges,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,AETNA [1000108],AETNA [100010801],,,76.8,,2367.72,7.2,2367.72096,percent of total billed charges,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,AETNA [1000108],AETNA [100010801],,,76.8,,64.4,0.32,416.02,percent of total billed charges,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,AETNA [1000108],AETNA [100010801],,,76.8,,90.13,0.32,416.02,percent of total billed charges,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,AETNA [1000108],AETNA [100010801],,,76.8,,2152.77,5.43,2152.77312,percent of total billed charges,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,AETNA [1000108],AETNA [100010801],,,76.8,,683.08,5.43,2152.77312,percent of total billed charges,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,AETNA [1000108],AETNA [100010801],,,76.8,,3900.27,12.95,3900.27264,percent of total billed charges,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,AETNA [1000108],AETNA [100010801],,,76.8,,7001.86,72.7,7001.856,percent of total billed charges,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,AETNA [1000108],AETNA [100010801],,,76.8,,1750.46,72.7,7001.856,percent of total billed charges,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,AETNA [1000108],AETNA [100010801],,,76.8,,92.28,14.931495,416.02,percent of total billed charges,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,AETNA [1000108],AETNA [100010801],,,76.8,,51.08,14.931495,416.02,percent of total billed charges,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,AETNA [1000108],AETNA [100010801],,,76.8,,45.08,1.57,905.322979,percent of total billed charges,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,AETNA [1000108],AETNA [100010801],,,76.8,,113.36,1.57,905.322979,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,AETNA [1000108],AETNA [100010801],,,76.8,,24824.62,221.96,24824.61696,percent of total billed charges,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,AETNA [1000108],AETNA [100010801],,,76.8,,30463.31,206.03,30463.31136,percent of total billed charges,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,AETNA [1000108],AETNA [100010801],,,76.8,,48.93,2.41,416.02,percent of total billed charges,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,AETNA [1000108],AETNA [100010801],,,76.8,,121.31,2.41,416.02,percent of total billed charges,
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,AETNA [1000108],AETNA [100010801],,,76.8,,6870.27,47.04,6870.26688,percent of total billed charges,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,AETNA [1000108],AETNA [100010801],,,76.8,,3359.08,72.08,3359.0784,percent of total billed charges,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,AETNA [1000108],AETNA [100010801],,,76.8,,1679.54,72.08,3359.0784,percent of total billed charges,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,AETNA [1000108],AETNA [100010801],,,76.8,,52.14,2.37,416.02,percent of total billed charges,
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,AETNA [1000108],AETNA [100010801],,,76.8,,267.05,14.25,416.02,percent of total billed charges,
CYCLOPHOSPHAMIDE 1 G IJ SOLR,RX-38270,CDM,J9070,HCPCS,636,RC,00781-3244-94,NDC,outpatient,1,UN,1602.63,1121.841,AETNA [1000108],AETNA [100010801],,,76.8,,1230.82,17.09,1230.81984,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9070,HCPCS,636,RC,00781-3233-94,NDC,outpatient,1,UN,1017.09,711.963,AETNA [1000108],AETNA [100010801],,,76.8,,781.13,17.09,1230.81984,percent of total billed charges,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9070,HCPCS,636,RC,10019-0957-01,NDC,outpatient,1,UN,1524.13,1066.891,AETNA [1000108],AETNA [100010801],,,76.8,,1170.53,17.09,1230.81984,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,AETNA [1000108],AETNA [100010801],,,76.8,,31.45,0.77,416.02,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,AETNA [1000108],AETNA [100010801],,,76.8,,40.93,0.77,416.02,percent of total billed charges,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,AETNA [1000108],AETNA [100010801],,,76.8,,47.95,0.77,416.02,percent of total billed charges,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,AETNA [1000108],AETNA [100010801],,,76.8,,12.91,0.77,416.02,percent of total billed charges,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,AETNA [1000108],AETNA [100010801],,,76.8,,12.91,0.77,416.02,percent of total billed charges,
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,AETNA [1000108],AETNA [100010801],,,76.8,,26.63,0.77,416.02,percent of total billed charges,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,AETNA [1000108],AETNA [100010801],,,76.8,,12.63,3.69078,416.02,percent of total billed charges,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,AETNA [1000108],AETNA [100010801],,,76.8,,12.63,3.69078,416.02,percent of total billed charges,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,AETNA [1000108],AETNA [100010801],,,76.8,,1339.56,4.18,1339.56096,percent of total billed charges,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,AETNA [1000108],AETNA [100010801],,,76.8,,858.58,4.18,1339.56096,percent of total billed charges,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,AETNA [1000108],AETNA [100010801],,,76.8,,472.93,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,AETNA [1000108],AETNA [100010801],,,76.8,,92.58,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,AETNA [1000108],AETNA [100010801],,,76.8,,557.57,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,AETNA [1000108],AETNA [100010801],,,76.8,,35.07,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,AETNA [1000108],AETNA [100010801],,,76.8,,139.39,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,AETNA [1000108],AETNA [100010801],,,76.8,,265.23,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,AETNA [1000108],AETNA [100010801],,,76.8,,1115.14,0.79,1115.136,percent of total billed charges,
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,AETNA [1000108],AETNA [100010801],,,76.8,,86.28,1.34,416.02,percent of total billed charges,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,AETNA [1000108],AETNA [100010801],,,76.8,,3097.04,128.78,3097.0368,percent of total billed charges,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,AETNA [1000108],AETNA [100010801],,,76.8,,25.99,0.7,416.02,percent of total billed charges,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,AETNA [1000108],AETNA [100010801],,,76.8,,129.98,0.7,416.02,percent of total billed charges,
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,AETNA [1000108],AETNA [100010801],,,76.8,,213.8,62.498555,604.75,percent of total billed charges,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,AETNA [1000108],AETNA [100010801],,,76.8,,76.53,1.83,416.02,percent of total billed charges,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,AETNA [1000108],AETNA [100010801],,,76.8,,6.47,1.83,416.02,percent of total billed charges,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,AETNA [1000108],AETNA [100010801],,,76.8,,6.47,1.83,416.02,percent of total billed charges,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,AETNA [1000108],AETNA [100010801],,,76.8,,24.14,2.79,416.02,percent of total billed charges,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,AETNA [1000108],AETNA [100010801],,,76.8,,102.65,2.79,416.02,percent of total billed charges,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,AETNA [1000108],AETNA [100010801],,,76.8,,21.36,2.79,416.02,percent of total billed charges,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,AETNA [1000108],AETNA [100010801],,,76.8,,48.8,2.79,416.02,percent of total billed charges,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,AETNA [1000108],AETNA [100010801],,,76.8,,2078.84,399.86,5828.5824,percent of total billed charges,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,AETNA [1000108],AETNA [100010801],,,76.8,,5828.58,399.86,5828.5824,percent of total billed charges,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,AETNA [1000108],AETNA [100010801],,,76.8,,20.19,2.5,416.02,percent of total billed charges,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,AETNA [1000108],AETNA [100010801],,,76.8,,43.69,2.5,416.02,percent of total billed charges,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,AETNA [1000108],AETNA [100010801],,,76.8,,33.4,2.5,416.02,percent of total billed charges,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,AETNA [1000108],AETNA [100010801],,,76.8,,4253.11,122.55,12759.31392,percent of total billed charges,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,AETNA [1000108],AETNA [100010801],,,76.8,,12759.31,122.55,12759.31392,percent of total billed charges,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,AETNA [1000108],AETNA [100010801],,,76.8,,72.46,21.181575,416.02,percent of total billed charges,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,AETNA [1000108],AETNA [100010801],,,76.8,,72.46,21.181575,416.02,percent of total billed charges,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,AETNA [1000108],AETNA [100010801],,,76.8,,269.53,21.181575,416.02,percent of total billed charges,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,AETNA [1000108],AETNA [100010801],,,76.8,,221.52,21.181575,416.02,percent of total billed charges,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,AETNA [1000108],AETNA [100010801],,,76.8,,221.52,21.181575,416.02,percent of total billed charges,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,AETNA [1000108],AETNA [100010801],,,76.8,,21.78,1.67,416.02,percent of total billed charges,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,AETNA [1000108],AETNA [100010801],,,76.8,,170.73,1.67,416.02,percent of total billed charges,
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,AETNA [1000108],AETNA [100010801],,,76.8,,93.51,27.33512,416.02,percent of total billed charges,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,AETNA [1000108],AETNA [100010801],,,76.8,,4355.14,165.86,17420.48256,percent of total billed charges,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,AETNA [1000108],AETNA [100010801],,,76.8,,13065.32,165.86,17420.48256,percent of total billed charges,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,AETNA [1000108],AETNA [100010801],,,76.8,,17420.48,165.86,17420.48256,percent of total billed charges,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,AETNA [1000108],AETNA [100010801],,,76.8,,1189.85,165.86,17420.48256,percent of total billed charges,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,AETNA [1000108],AETNA [100010801],,,76.8,,18741.45,167.93,74965.60128,percent of total billed charges,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,AETNA [1000108],AETNA [100010801],,,76.8,,74965.6,167.93,74965.60128,percent of total billed charges,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-38,NDC,outpatient,0.5,ML,3.4,2.38,AETNA [1000108],AETNA [100010801],,,76.8,,2.61,0.27,416.02,percent of total billed charges,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-37,NDC,outpatient,0.5,ML,3.4,2.38,AETNA [1000108],AETNA [100010801],,,76.8,,2.61,0.27,416.02,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,AETNA [1000108],AETNA [100010801],,,76.8,,5.05,1.47721,416.02,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,AETNA [1000108],AETNA [100010801],,,76.8,,5.05,1.47721,416.02,percent of total billed charges,
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,AETNA [1000108],AETNA [100010801],,,76.8,,1721.83,72.53,1721.82528,percent of total billed charges,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,AETNA [1000108],AETNA [100010801],,,76.8,,166.38,0.06,416.02,percent of total billed charges,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,AETNA [1000108],AETNA [100010801],,,76.8,,38.65,0.06,416.02,percent of total billed charges,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,AETNA [1000108],AETNA [100010801],,,76.8,,3366.46,12.06,3366.45888,percent of total billed charges,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,AETNA [1000108],AETNA [100010801],,,76.8,,183.02,0.1,416.02,percent of total billed charges,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,AETNA [1000108],AETNA [100010801],,,76.8,,333.01,0.1,416.02,percent of total billed charges,
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,AETNA [1000108],AETNA [100010801],,,76.8,,4898.22,399.86,4898.21952,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,AETNA [1000108],AETNA [100010801],,,76.8,,12451.15,54.81,12451.14624,percent of total billed charges,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,AETNA [1000108],AETNA [100010801],,,76.8,,388.27,42.51,2565.35808,percent of total billed charges,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,AETNA [1000108],AETNA [100010801],,,76.8,,2565.27,42.51,2565.35808,percent of total billed charges,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,AETNA [1000108],AETNA [100010801],,,76.8,,2565.36,42.51,2565.35808,percent of total billed charges,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,AETNA [1000108],AETNA [100010801],,,76.8,,563.98,42.51,2565.35808,percent of total billed charges,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,AETNA [1000108],AETNA [100010801],,,76.8,,215.03,29.06,416.02,percent of total billed charges,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,AETNA [1000108],AETNA [100010801],,,76.8,,16440.55,30.46,16440.55296,percent of total billed charges,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,AETNA [1000108],AETNA [100010801],,,76.8,,2740.09,30.46,16440.55296,percent of total billed charges,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,AETNA [1000108],AETNA [100010801],,,76.8,,6850.21,30.46,16440.55296,percent of total billed charges,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,AETNA [1000108],AETNA [100010801],,,76.8,,18103.04,70.55,18103.04256,percent of total billed charges,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,AETNA [1000108],AETNA [100010801],,,76.8,,3510.73,149.71,14042.8032,percent of total billed charges,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,AETNA [1000108],AETNA [100010801],,,76.8,,14042.8,149.71,14042.8032,percent of total billed charges,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,AETNA [1000108],AETNA [100010801],,,76.8,,8613.96,4.18,8613.9648,percent of total billed charges,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,AETNA [1000108],AETNA [100010801],,,76.8,,1722.79,4.18,8613.9648,percent of total billed charges,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,AETNA [1000108],AETNA [100010801],,,76.8,,14335.96,15.37,14335.95648,percent of total billed charges,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,AETNA [1000108],AETNA [100010801],,,76.8,,15644.98,356.51,15644.98176,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,AETNA [1000108],AETNA [100010801],,,76.8,,3137.08,68.87,15685.39392,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,AETNA [1000108],AETNA [100010801],,,76.8,,15685.39,68.87,15685.39392,percent of total billed charges,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,AETNA [1000108],AETNA [100010801],,,76.8,,2063.64,77.31,10318.18752,percent of total billed charges,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,AETNA [1000108],AETNA [100010801],,,76.8,,10318.19,77.31,10318.18752,percent of total billed charges,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,AETNA [1000108],AETNA [100010801],,,76.8,,900.09,223.44,900.08832,percent of total billed charges,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,AETNA [1000108],AETNA [100010801],,,76.8,,4261.85,32.21,4261.85472,percent of total billed charges,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,AETNA [1000108],AETNA [100010801],,,76.8,,202.21,0.5,416.02,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,AETNA [1000108],AETNA [100010801],,,76.8,,8548.15,38.33,13677.02016,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,AETNA [1000108],AETNA [100010801],,,76.8,,13677.02,38.33,13677.02016,percent of total billed charges,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,AETNA [1000108],AETNA [100010801],,,76.8,,3651.08,77.94,3651.07968,percent of total billed charges,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,AETNA [1000108],AETNA [100010801],JW,,76.8,,3422.89,77.94,3651.07968,percent of total billed charges,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,AETNA [1000108],AETNA [100010801],,,76.8,,133.29,3.95,416.02,percent of total billed charges,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,AETNA [1000108],AETNA [100010801],,,76.8,,35.35,7.49,416.02,percent of total billed charges,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,AETNA [1000108],AETNA [100010801],,,76.8,,70.92,7.49,416.02,percent of total billed charges,
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,AETNA [1000108],AETNA [100010801],,,76.8,,125.21,7.59,416.02,percent of total billed charges,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,AETNA [1000108],AETNA [100010801],,,76.8,,397.88,1.65,1060,percent of total billed charges,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,AETNA [1000108],AETNA [100010801],,,76.8,,397.88,1.65,1060,percent of total billed charges,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,76.8,,134.44,4.41367,416.02,percent of total billed charges,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,4.41367,416.02,percent of total billed charges,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,AETNA [1000108],AETNA [100010801],,,76.8,,15.1,4.41367,416.02,percent of total billed charges,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,AETNA [1000108],AETNA [100010801],,,76.8,,18.24,4.41367,416.02,percent of total billed charges,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA [1000108],AETNA [100010801],,,76.8,,97.42,12.10504,416.02,percent of total billed charges,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA [1000108],AETNA [100010801],,,76.8,,97.42,12.10504,416.02,percent of total billed charges,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA [1000108],AETNA [100010801],,,76.8,,97.42,12.10504,416.02,percent of total billed charges,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,AETNA [1000108],AETNA [100010801],,,76.8,,41.41,12.10504,416.02,percent of total billed charges,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,AETNA [1000108],AETNA [100010801],,,76.8,,41.41,12.10504,416.02,percent of total billed charges,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA [1000108],AETNA [100010801],,,76.8,,50.86,12.10504,416.02,percent of total billed charges,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA [1000108],AETNA [100010801],,,76.8,,50.86,12.10504,416.02,percent of total billed charges,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA [1000108],AETNA [100010801],,,76.8,,50.86,12.10504,416.02,percent of total billed charges,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,AETNA [1000108],AETNA [100010801],,,76.8,,51.04,12.10504,416.02,percent of total billed charges,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,AETNA [1000108],AETNA [100010801],,,76.8,,51.04,12.10504,416.02,percent of total billed charges,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,AETNA [1000108],AETNA [100010801],,,76.8,,104.5,29.06826,416.02,percent of total billed charges,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,AETNA [1000108],AETNA [100010801],,,76.8,,99.44,29.06826,416.02,percent of total billed charges,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,AETNA [1000108],AETNA [100010801],,,76.8,,104.55,29.06826,416.02,percent of total billed charges,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,AETNA [1000108],AETNA [100010801],,,76.8,,104.5,29.06826,416.02,percent of total billed charges,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,AETNA [1000108],AETNA [100010801],,,76.8,,99.44,29.06826,416.02,percent of total billed charges,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,AETNA [1000108],AETNA [100010801],,,76.8,,418.55,110.03643,1222.676,percent of total billed charges,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,AETNA [1000108],AETNA [100010801],,,76.8,,418.55,110.03643,1222.676,percent of total billed charges,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,110.03643,1222.676,percent of total billed charges,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,AETNA [1000108],AETNA [100010801],,,76.8,,81.07,23.579235,416.02,percent of total billed charges,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,AETNA [1000108],AETNA [100010801],,,76.8,,80.66,23.579235,416.02,percent of total billed charges,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,AETNA [1000108],AETNA [100010801],,,76.8,,81.07,23.579235,416.02,percent of total billed charges,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,AETNA [1000108],AETNA [100010801],,,76.8,,85.59,23.579235,416.02,percent of total billed charges,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,AETNA [1000108],AETNA [100010801],,,76.8,,138.61,34.77954,420.504,percent of total billed charges,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,AETNA [1000108],AETNA [100010801],,,76.8,,138.07,34.77954,420.504,percent of total billed charges,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,AETNA [1000108],AETNA [100010801],,,76.8,,138.61,34.77954,420.504,percent of total billed charges,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,AETNA [1000108],AETNA [100010801],,,76.8,,134.62,34.77954,420.504,percent of total billed charges,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,AETNA [1000108],AETNA [100010801],,,76.8,,173.74,34.77954,420.504,percent of total billed charges,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,AETNA [1000108],AETNA [100010801],,,76.8,,118.98,34.77954,420.504,percent of total billed charges,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,AETNA [1000108],AETNA [100010801],,,76.8,,118.98,34.77954,420.504,percent of total billed charges,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA [1000108],AETNA [100010801],,,76.8,,56.42,16.49177,416.02,percent of total billed charges,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA [1000108],AETNA [100010801],,,76.8,,56.42,16.49177,416.02,percent of total billed charges,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA [1000108],AETNA [100010801],,,76.8,,56.42,16.49177,416.02,percent of total billed charges,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA [1000108],AETNA [100010801],,,76.8,,24.47,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA [1000108],AETNA [100010801],,,76.8,,24.47,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA [1000108],AETNA [100010801],,,76.8,,24.47,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA [1000108],AETNA [100010801],,,76.8,,23.71,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA [1000108],AETNA [100010801],,,76.8,,23.71,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA [1000108],AETNA [100010801],,,76.8,,23.71,4.63817,482.28096,percent of total billed charges,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,AETNA [1000108],AETNA [100010801],,,76.8,,20.93,4.63817,482.28096,percent of total billed charges,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,AETNA [1000108],AETNA [100010801],,,76.8,,21.2,4.63817,482.28096,percent of total billed charges,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,AETNA [1000108],AETNA [100010801],,,76.8,,20.93,4.63817,482.28096,percent of total billed charges,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,AETNA [1000108],AETNA [100010801],,,76.8,,30.38,4.63817,482.28096,percent of total billed charges,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,AETNA [1000108],AETNA [100010801],,,76.8,,170.29,4.63817,482.28096,percent of total billed charges,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,76.8,,164.69,4.63817,482.28096,percent of total billed charges,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,76.8,,164.69,4.63817,482.28096,percent of total billed charges,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,AETNA [1000108],AETNA [100010801],,,76.8,,89.4,4.63817,482.28096,percent of total billed charges,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,AETNA [1000108],AETNA [100010801],,,76.8,,95.63,4.63817,482.28096,percent of total billed charges,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,AETNA [1000108],AETNA [100010801],,,76.8,,15.87,4.63817,482.28096,percent of total billed charges,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,AETNA [1000108],AETNA [100010801],,,76.8,,17.12,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,AETNA [1000108],AETNA [100010801],,,76.8,,84.79,4.63817,482.28096,percent of total billed charges,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,AETNA [1000108],AETNA [100010801],,,76.8,,21.86,4.63817,482.28096,percent of total billed charges,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,AETNA [1000108],AETNA [100010801],,,76.8,,36.26,4.63817,482.28096,percent of total billed charges,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,AETNA [1000108],AETNA [100010801],,,76.8,,37.29,4.63817,482.28096,percent of total billed charges,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,AETNA [1000108],AETNA [100010801],,,76.8,,37.29,4.63817,482.28096,percent of total billed charges,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,AETNA [1000108],AETNA [100010801],,,76.8,,21.86,4.63817,482.28096,percent of total billed charges,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,76.8,,35.04,4.63817,482.28096,percent of total billed charges,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,AETNA [1000108],AETNA [100010801],,,76.8,,302.26,4.63817,482.28096,percent of total billed charges,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,AETNA [1000108],AETNA [100010801],,,76.8,,341.25,4.63817,482.28096,percent of total billed charges,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,AETNA [1000108],AETNA [100010801],,,76.8,,413.4,4.63817,482.28096,percent of total billed charges,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,AETNA [1000108],AETNA [100010801],,,76.8,,482.28,4.63817,482.28096,percent of total billed charges,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,AETNA [1000108],AETNA [100010801],,,76.8,,482.28,4.63817,482.28096,percent of total billed charges,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,AETNA [1000108],AETNA [100010801],,,76.8,,179.25,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,AETNA [1000108],AETNA [100010801],,,76.8,,234.59,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,AETNA [1000108],AETNA [100010801],,,76.8,,234.59,3.81201,416.02,percent of total billed charges,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,AETNA [1000108],AETNA [100010801],,,76.8,,285.1,3.81201,416.02,percent of total billed charges,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,AETNA [1000108],AETNA [100010801],,,76.8,,186.73,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,AETNA [1000108],AETNA [100010801],,,76.8,,186.73,3.81201,416.02,percent of total billed charges,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,AETNA [1000108],AETNA [100010801],,,76.8,,22.81,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,AETNA [1000108],AETNA [100010801],,,76.8,,22.81,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,AETNA [1000108],AETNA [100010801],,,76.8,,263.5,3.81201,416.02,percent of total billed charges,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,AETNA [1000108],AETNA [100010801],,,76.8,,22.36,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,AETNA [1000108],AETNA [100010801],,,76.8,,43.2,3.81201,416.02,percent of total billed charges,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,3.81201,416.02,percent of total billed charges,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,AETNA [1000108],AETNA [100010801],,,76.8,,13.04,3.81201,416.02,percent of total billed charges,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,AETNA [1000108],AETNA [100010801],,,76.8,,23.88,3.81201,416.02,percent of total billed charges,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,AETNA [1000108],AETNA [100010801],,,76.8,,219.86,31.76675,416.02,percent of total billed charges,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,AETNA [1000108],AETNA [100010801],,,76.8,,218.42,31.76675,416.02,percent of total billed charges,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,AETNA [1000108],AETNA [100010801],,,76.8,,209.73,31.76675,416.02,percent of total billed charges,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,AETNA [1000108],AETNA [100010801],,,76.8,,108.67,31.76675,416.02,percent of total billed charges,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,AETNA [1000108],AETNA [100010801],,,76.8,,5378,335.72,5377.9968,percent of total billed charges,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,AETNA [1000108],AETNA [100010801],,,76.8,,52.43,15.326615,416.02,percent of total billed charges,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,AETNA [1000108],AETNA [100010801],,,76.8,,71.16,15.326615,416.02,percent of total billed charges,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,AETNA [1000108],AETNA [100010801],,,76.8,,71.16,15.326615,416.02,percent of total billed charges,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,AETNA [1000108],AETNA [100010801],,,76.8,,68.47,17.225885,416.02,percent of total billed charges,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,AETNA [1000108],AETNA [100010801],,,76.8,,58.93,17.225885,416.02,percent of total billed charges,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,AETNA [1000108],AETNA [100010801],,,76.8,,58.97,17.225885,416.02,percent of total billed charges,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,AETNA [1000108],AETNA [100010801],,,76.8,,206.99,50.613525,568.638,percent of total billed charges,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,AETNA [1000108],AETNA [100010801],,,76.8,,206.99,50.613525,568.638,percent of total billed charges,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,AETNA [1000108],AETNA [100010801],,,76.8,,202.64,50.613525,568.638,percent of total billed charges,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,AETNA [1000108],AETNA [100010801],,,76.8,,202.64,50.613525,568.638,percent of total billed charges,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,AETNA [1000108],AETNA [100010801],,,76.8,,173.15,50.613525,568.638,percent of total billed charges,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,AETNA [1000108],AETNA [100010801],,,76.8,,210.89,50.613525,568.638,percent of total billed charges,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,AETNA [1000108],AETNA [100010801],,,76.8,,191.8,50.613525,568.638,percent of total billed charges,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,AETNA [1000108],AETNA [100010801],,,76.8,,179.97,50.613525,568.638,percent of total billed charges,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,AETNA [1000108],AETNA [100010801],,,76.8,,97.61,20.61,416.02,percent of total billed charges,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA [1000108],AETNA [100010801],,,76.8,,329.83,52.37136,418.655068,percent of total billed charges,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,AETNA [1000108],AETNA [100010801],,,76.8,,379.34,52.37136,418.655068,percent of total billed charges,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA [1000108],AETNA [100010801],,,76.8,,329.83,52.37136,418.655068,percent of total billed charges,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA [1000108],AETNA [100010801],,,76.8,,329.83,52.37136,418.655068,percent of total billed charges,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,AETNA [1000108],AETNA [100010801],,,76.8,,179.16,52.37136,418.655068,percent of total billed charges,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,AETNA [1000108],AETNA [100010801],,,76.8,,1058.4,125.65,1058.40384,percent of total billed charges,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,AETNA [1000108],AETNA [100010801],,,76.8,,1058.4,125.65,1058.40384,percent of total billed charges,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,399.86,3409.78176,percent of total billed charges,
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,252.25,3748.3008,percent of total billed charges,
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,AETNA [1000108],AETNA [100010801],,,76.8,,1517.14,252.25,3748.3008,percent of total billed charges,
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,70.737705,686.06,percent of total billed charges,
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,60.258045,2016.5376,percent of total billed charges,
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,AETNA [1000108],AETNA [100010801],,,76.8,,1970.26,60.258045,2016.5376,percent of total billed charges,
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,60.258045,2016.5376,percent of total billed charges,
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,60.258045,2016.5376,percent of total billed charges,
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,AETNA [1000108],AETNA [100010801],,,76.8,,936.28,60.258045,2016.5376,percent of total billed charges,
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,AETNA [1000108],AETNA [100010801],,,76.8,,998.44,60.258045,2016.5376,percent of total billed charges,
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,AETNA [1000108],AETNA [100010801],,,76.8,,482.81,60.258045,2016.5376,percent of total billed charges,
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,AETNA [1000108],AETNA [100010801],,,76.8,,266.19,60.258045,2016.5376,percent of total billed charges,
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,AETNA [1000108],AETNA [100010801],,,76.8,,206.14,60.258045,2016.5376,percent of total billed charges,
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA [1000108],AETNA [100010801],,,76.8,,779.21,60.258045,2016.5376,percent of total billed charges,
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA [1000108],AETNA [100010801],,,76.8,,779.21,60.258045,2016.5376,percent of total billed charges,
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA [1000108],AETNA [100010801],,,76.8,,779.21,60.258045,2016.5376,percent of total billed charges,
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,AETNA [1000108],AETNA [100010801],,,76.8,,787,60.258045,2016.5376,percent of total billed charges,
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA [1000108],AETNA [100010801],,,76.8,,779.21,60.258045,2016.5376,percent of total billed charges,
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,AETNA [1000108],AETNA [100010801],,,76.8,,816.49,60.258045,2016.5376,percent of total billed charges,
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,AETNA [1000108],AETNA [100010801],,,76.8,,823.61,60.258045,2016.5376,percent of total billed charges,
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,AETNA [1000108],AETNA [100010801],,,76.8,,1676.02,60.258045,2016.5376,percent of total billed charges,
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,AETNA [1000108],AETNA [100010801],,,76.8,,1565.46,60.258045,2016.5376,percent of total billed charges,
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,AETNA [1000108],AETNA [100010801],,,76.8,,1693.85,60.258045,2016.5376,percent of total billed charges,
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,AETNA [1000108],AETNA [100010801],,,76.8,,584.89,60.258045,2016.5376,percent of total billed charges,
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA [1000108],AETNA [100010801],,,76.8,,1431.05,60.258045,2016.5376,percent of total billed charges,
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA [1000108],AETNA [100010801],,,76.8,,1431.05,60.258045,2016.5376,percent of total billed charges,
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA [1000108],AETNA [100010801],,,76.8,,1431.05,60.258045,2016.5376,percent of total billed charges,
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,AETNA [1000108],AETNA [100010801],,,76.8,,1422.86,60.258045,2016.5376,percent of total billed charges,
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,AETNA [1000108],AETNA [100010801],,,76.8,,1422.86,60.258045,2016.5376,percent of total billed charges,
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA [1000108],AETNA [100010801],,,76.8,,1230.27,60.258045,2016.5376,percent of total billed charges,
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA [1000108],AETNA [100010801],,,76.8,,1230.27,60.258045,2016.5376,percent of total billed charges,
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA [1000108],AETNA [100010801],,,76.8,,1230.27,60.258045,2016.5376,percent of total billed charges,
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,60.258045,2016.5376,percent of total billed charges,
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,AETNA [1000108],AETNA [100010801],,,76.8,,3534.81,399.86,3534.81216,percent of total billed charges,
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,AETNA [1000108],AETNA [100010801],,,76.8,,3389.77,399.86,3534.81216,percent of total billed charges,
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,AETNA [1000108],AETNA [100010801],,,76.8,,6505.74,163.74581,6505.74336,percent of total billed charges,
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,AETNA [1000108],AETNA [100010801],,,76.8,,5378,163.74581,6505.74336,percent of total billed charges,
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,163.74581,6505.74336,percent of total billed charges,
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA [1000108],AETNA [100010801],,,76.8,,1343.36,163.74581,6505.74336,percent of total billed charges,
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,AETNA [1000108],AETNA [100010801],,,76.8,,3829.79,163.74581,6505.74336,percent of total billed charges,
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,AETNA [1000108],AETNA [100010801],,,76.8,,3340.88,163.74581,6505.74336,percent of total billed charges,
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,163.74581,6505.74336,percent of total billed charges,
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,163.74581,6505.74336,percent of total billed charges,
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,163.74581,6505.74336,percent of total billed charges,
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,AETNA [1000108],AETNA [100010801],,,76.8,,1117.44,326.6475,1117.44,percent of total billed charges,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,AETNA [1000108],AETNA [100010801],,,76.8,,942.34,49.4,942.336,percent of total billed charges,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,AETNA [1000108],AETNA [100010801],,,76.8,,423.17,123.6995,423.168,percent of total billed charges,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,AETNA [1000108],AETNA [100010801],,,76.8,,291.07,71.53,416.02,percent of total billed charges,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,76.8,,361.73,105.7395,416.02,percent of total billed charges,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,AETNA [1000108],AETNA [100010801],,,76.8,,789.5,163,871.3328,percent of total billed charges,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,AETNA [1000108],AETNA [100010801],,,76.8,,1072.9,136.61,1072.896,percent of total billed charges,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,AETNA [1000108],AETNA [100010801],,,76.8,,1254.14,163,1384.1308,percent of total billed charges,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,AETNA [1000108],AETNA [100010801],,,76.8,,946.94,163,1119.53,percent of total billed charges,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,AETNA [1000108],AETNA [100010801],,,76.8,,1247.23,163,1476.21,percent of total billed charges,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,AETNA [1000108],AETNA [100010801],,,76.8,,1986.05,163,2191.8936,percent of total billed charges,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,AETNA [1000108],AETNA [100010801],,,76.8,,488.45,142.782,598.2,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,AETNA [1000108],AETNA [100010801],,,76.8,,153.27,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,AETNA [1000108],AETNA [100010801],,,76.8,,153.27,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,AETNA [1000108],AETNA [100010801],,,76.8,,129.35,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,AETNA [1000108],AETNA [100010801],,,76.8,,131.9,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,AETNA [1000108],AETNA [100010801],,,76.8,,86.62,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,AETNA [1000108],AETNA [100010801],,,76.8,,129.35,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,AETNA [1000108],AETNA [100010801],,,76.8,,131.9,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,AETNA [1000108],AETNA [100010801],,,76.8,,86.62,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,AETNA [1000108],AETNA [100010801],,,76.8,,278.86,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,AETNA [1000108],AETNA [100010801],JW,,76.8,,266.57,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,AETNA [1000108],AETNA [100010801],,,76.8,,160.96,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,AETNA [1000108],AETNA [100010801],,,76.8,,37.24,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,AETNA [1000108],AETNA [100010801],,,76.8,,237.85,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,AETNA [1000108],AETNA [100010801],,,76.8,,237.85,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,AETNA [1000108],AETNA [100010801],,,76.8,,246.4,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,AETNA [1000108],AETNA [100010801],JW,,76.8,,24.95,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,AETNA [1000108],AETNA [100010801],JW,,76.8,,225.56,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,AETNA [1000108],AETNA [100010801],JW,,76.8,,234.11,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,AETNA [1000108],AETNA [100010801],,,76.8,,37.24,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,AETNA [1000108],AETNA [100010801],JW,,76.8,,24.95,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,AETNA [1000108],AETNA [100010801],JW,,76.8,,225.56,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,AETNA [1000108],AETNA [100010801],JW,,76.8,,318.18,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,AETNA [1000108],AETNA [100010801],,,76.8,,330.47,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,AETNA [1000108],AETNA [100010801],,,76.8,,160.96,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,AETNA [1000108],AETNA [100010801],,,76.8,,129.35,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,AETNA [1000108],AETNA [100010801],,,76.8,,246.4,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,AETNA [1000108],AETNA [100010801],,,76.8,,129.35,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,AETNA [1000108],AETNA [100010801],JW,,76.8,,234.11,7.294005,416.02,percent of total billed charges,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,AETNA [1000108],AETNA [100010801],,,76.8,,1387.78,163,1698,percent of total billed charges,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,AETNA [1000108],AETNA [100010801],,,76.8,,1583.62,163,1747.7512,percent of total billed charges,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,AETNA [1000108],AETNA [100010801],,,76.8,,948.48,163,1046.786,percent of total billed charges,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,49.839,416.02,percent of total billed charges,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,AETNA [1000108],AETNA [100010801],,,76.8,,1248.77,163,1265.41,percent of total billed charges,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,AETNA [1000108],AETNA [100010801],,,76.8,,68.35,19.9805,416.02,percent of total billed charges,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,AETNA [1000108],AETNA [100010801],,,76.8,,726.31,0.34,726.30528,percent of total billed charges,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,AETNA [1000108],AETNA [100010801],,,76.8,,1.21,0.01,416.02,percent of total billed charges,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.01,416.02,percent of total billed charges,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.01,416.02,percent of total billed charges,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.01,416.02,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,AETNA [1000108],AETNA [100010801],,,76.8,,2.73,0.35,416.02,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,AETNA [1000108],AETNA [100010801],,,76.8,,2.73,0.35,416.02,percent of total billed charges,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,AETNA [1000108],AETNA [100010801],,,76.8,,14.45,0.73,416.02,percent of total billed charges,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,AETNA [1000108],AETNA [100010801],,,76.8,,14.45,0.73,416.02,percent of total billed charges,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.09,416.02,percent of total billed charges,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.09,416.02,percent of total billed charges,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,AETNA [1000108],AETNA [100010801],,,76.8,,59.84,2.55,416.02,percent of total billed charges,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,AETNA [1000108],AETNA [100010801],,,76.8,,59.84,2.55,416.02,percent of total billed charges,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,AETNA [1000108],AETNA [100010801],,,76.8,,15.17,2.55,416.02,percent of total billed charges,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,AETNA [1000108],AETNA [100010801],,,76.8,,15.17,2.55,416.02,percent of total billed charges,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,AETNA [1000108],AETNA [100010801],,,76.8,,1081.68,87.98,1653.428703,percent of total billed charges,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,AETNA [1000108],AETNA [100010801],,,76.8,,1220.94,87.98,1653.428703,percent of total billed charges,
HC Telehealth Originating Site Facility Fee,PX-78000001,CDM,Q3014,HCPCS,780,RC,,,outpatient,,,373,261.1,AETNA [1000108],AETNA [100010801],,,76.8,,286.46,83.7385,416.02,percent of total billed charges,
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,AETNA [1000108],AETNA [100010801],,,76.8,,1193.43,348.861775,3862.93248,percent of total billed charges,
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,AETNA [1000108],AETNA [100010801],,,76.8,,1912.7,348.861775,3862.93248,percent of total billed charges,
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,AETNA [1000108],AETNA [100010801],,,76.8,,3104.48,348.861775,3862.93248,percent of total billed charges,
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,AETNA [1000108],AETNA [100010801],,,76.8,,3862.93,348.861775,3862.93248,percent of total billed charges,
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,AETNA [1000108],AETNA [100010801],,,76.8,,6716.16,30.42,6716.16,percent of total billed charges,
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,AETNA [1000108],AETNA [100010801],,,76.8,,49.92,12.25,659.42016,percent of total billed charges,
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,AETNA [1000108],AETNA [100010801],,,76.8,,659.42,12.25,659.42016,percent of total billed charges,
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,AETNA [1000108],AETNA [100010801],,,76.8,,18968.74,48.96,24594.91584,percent of total billed charges,
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,AETNA [1000108],AETNA [100010801],,,76.8,,15697.97,48.96,24594.91584,percent of total billed charges,
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,AETNA [1000108],AETNA [100010801],,,76.8,,24594.92,48.96,24594.91584,percent of total billed charges,
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,AETNA [1000108],AETNA [100010801],,,76.8,,142.85,41.757,4074.24,percent of total billed charges,
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,AETNA [1000108],AETNA [100010801],,,76.8,,1656.81,41.757,4074.24,percent of total billed charges,
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,76.8,,1815.57,41.757,4074.24,percent of total billed charges,
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,41.757,4074.24,percent of total billed charges,
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,AETNA [1000108],AETNA [100010801],,,76.8,,2361.19,41.757,4074.24,percent of total billed charges,
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,41.757,4074.24,percent of total billed charges,
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,41.757,4074.24,percent of total billed charges,
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,AETNA [1000108],AETNA [100010801],,,76.8,,4377.88,31.11,14996.48256,percent of total billed charges,
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,AETNA [1000108],AETNA [100010801],,,76.8,,3575.55,31.11,14996.48256,percent of total billed charges,
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,AETNA [1000108],AETNA [100010801],,,76.8,,8418.73,31.11,14996.48256,percent of total billed charges,
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,AETNA [1000108],AETNA [100010801],,,76.8,,14996.48,31.11,14996.48256,percent of total billed charges,
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,AETNA [1000108],AETNA [100010801],,,76.8,,11725.72,31.11,14996.48256,percent of total billed charges,
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,AETNA [1000108],AETNA [100010801],,,76.8,,2250.09,2.5,8051.0208,percent of total billed charges,
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,AETNA [1000108],AETNA [100010801],,,76.8,,4399.53,2.5,8051.0208,percent of total billed charges,
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,AETNA [1000108],AETNA [100010801],,,76.8,,8051.02,2.5,8051.0208,percent of total billed charges,
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,46.98,6518.784,percent of total billed charges,
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,AETNA [1000108],AETNA [100010801],,,76.8,,46.85,9.16,4034.304,percent of total billed charges,
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,AETNA [1000108],AETNA [100010801],,,76.8,,4034.3,9.16,4034.304,percent of total billed charges,
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,AETNA [1000108],AETNA [100010801],,,76.8,,5974.46,209.5932,10851.38688,percent of total billed charges,
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,AETNA [1000108],AETNA [100010801],,,76.8,,9048.08,209.5932,10851.38688,percent of total billed charges,
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,AETNA [1000108],AETNA [100010801],,,76.8,,10851.39,209.5932,10851.38688,percent of total billed charges,
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,209.5932,10851.38688,percent of total billed charges,
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,AETNA [1000108],AETNA [100010801],,,76.8,,3983.95,209.5932,10851.38688,percent of total billed charges,
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,AETNA [1000108],AETNA [100010801],,,76.8,,12381.58,3.06,20434.45248,percent of total billed charges,
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,AETNA [1000108],AETNA [100010801],,,76.8,,8298.11,3.06,20434.45248,percent of total billed charges,
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,AETNA [1000108],AETNA [100010801],,,76.8,,5325.85,3.06,20434.45248,percent of total billed charges,
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,AETNA [1000108],AETNA [100010801],,,76.8,,20434.45,3.06,20434.45248,percent of total billed charges,
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,AETNA [1000108],AETNA [100010801],,,76.8,,12261.81,3.06,20434.45248,percent of total billed charges,
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,AETNA [1000108],AETNA [100010801],,,76.8,,3463.1,18.9,9453.0048,percent of total billed charges,
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,AETNA [1000108],AETNA [100010801],,,76.8,,6233.59,18.9,9453.0048,percent of total billed charges,
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,AETNA [1000108],AETNA [100010801],,,76.8,,655.17,18.9,9453.0048,percent of total billed charges,
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,AETNA [1000108],AETNA [100010801],,,76.8,,3163.22,18.9,9453.0048,percent of total billed charges,
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,AETNA [1000108],AETNA [100010801],,,76.8,,6302.85,18.9,9453.0048,percent of total billed charges,
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,AETNA [1000108],AETNA [100010801],,,76.8,,9453,18.9,9453.0048,percent of total billed charges,
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,AETNA [1000108],AETNA [100010801],,,76.8,,3740.15,18.9,9453.0048,percent of total billed charges,
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,AETNA [1000108],AETNA [100010801],,,76.8,,7344.25,18.9,9453.0048,percent of total billed charges,
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,AETNA [1000108],AETNA [100010801],,,76.8,,384.77,112.4745,3643.99872,percent of total billed charges,
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,AETNA [1000108],AETNA [100010801],,,76.8,,1341.32,112.4745,3643.99872,percent of total billed charges,
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,AETNA [1000108],AETNA [100010801],,,76.8,,2867.15,112.4745,3643.99872,percent of total billed charges,
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,AETNA [1000108],AETNA [100010801],,,76.8,,3644,112.4745,3643.99872,percent of total billed charges,
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,102.28,3422.3616,percent of total billed charges,
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,102.28,3422.3616,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,AETNA [1000108],AETNA [100010801],,,76.8,,463.19,0.18,741.12768,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,AETNA [1000108],AETNA [100010801],,,76.8,,463.21,0.18,741.12768,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,AETNA [1000108],AETNA [100010801],,,76.8,,463.21,0.18,741.12768,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,AETNA [1000108],AETNA [100010801],,,76.8,,741.13,0.18,741.12768,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,AETNA [1000108],AETNA [100010801],,,76.8,,741.13,0.18,741.12768,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,AETNA [1000108],AETNA [100010801],,,76.8,,1067.26,13.62,1653.428703,percent of total billed charges,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,AETNA [1000108],AETNA [100010801],,,76.8,,1461.03,27.18,1653.428703,percent of total billed charges,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,AETNA [1000108],AETNA [100010801],,,76.8,,1461.03,27.18,1653.428703,percent of total billed charges,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,AETNA [1000108],AETNA [100010801],,,76.8,,61.03,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,AETNA [1000108],AETNA [100010801],,,76.8,,61.03,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,AETNA [1000108],AETNA [100010801],,,76.8,,91.54,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,AETNA [1000108],AETNA [100010801],,,76.8,,91.54,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,AETNA [1000108],AETNA [100010801],,,76.8,,122.05,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,AETNA [1000108],AETNA [100010801],,,76.8,,122.05,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,AETNA [1000108],AETNA [100010801],,,76.8,,290.07,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,AETNA [1000108],AETNA [100010801],,,76.8,,290.07,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,AETNA [1000108],AETNA [100010801],,,76.8,,58.01,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,AETNA [1000108],AETNA [100010801],,,76.8,,58.01,7.5,416.02,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,AETNA [1000108],AETNA [100010801],,,76.8,,1298.86,33.59,7269.974281,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,AETNA [1000108],AETNA [100010801],,,76.8,,5116.7,33.59,7269.974281,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,AETNA [1000108],AETNA [100010801],,,76.8,,1590.9,21.29,1590.89664,percent of total billed charges,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,40.92,438.4896,percent of total billed charges,
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,AETNA [1000108],AETNA [100010801],,,76.8,,438.49,40.92,438.4896,percent of total billed charges,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.22,416.02,percent of total billed charges,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,1.56,416.02,percent of total billed charges,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,1.56,416.02,percent of total billed charges,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,AETNA [1000108],AETNA [100010801],,,76.8,,75.34,0.38,416.02,percent of total billed charges,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,AETNA [1000108],AETNA [100010801],,,76.8,,25.11,0.38,416.02,percent of total billed charges,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,AETNA [1000108],AETNA [100010801],,,76.8,,25.11,0.38,416.02,percent of total billed charges,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,AETNA [1000108],AETNA [100010801],,,76.8,,25.11,0.38,416.02,percent of total billed charges,
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,AETNA [1000108],AETNA [100010801],,,76.8,,62.78,0.14,416.02,percent of total billed charges,
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,AETNA [1000108],AETNA [100010801],,,76.8,,209.28,0.14,416.02,percent of total billed charges,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,AETNA [1000108],AETNA [100010801],,,76.8,,125.57,0.14,416.02,percent of total billed charges,
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,AETNA [1000108],AETNA [100010801],,,76.8,,83.71,0.14,416.02,percent of total billed charges,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,AETNA [1000108],AETNA [100010801],,,76.8,,2181.73,9.53,2181.7344,percent of total billed charges,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,AETNA [1000108],AETNA [100010801],,,76.8,,2181.73,9.53,2181.7344,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-00,NDC,outpatient,650,ME,11.57,8.099,AETNA [1000108],AETNA [100010801],,,76.8,,8.89,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-30,NDC,outpatient,650,ME,11.57,8.099,AETNA [1000108],AETNA [100010801],,,76.8,,8.89,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-21,NDC,outpatient,650,ME,11.57,8.099,AETNA [1000108],AETNA [100010801],,,76.8,,8.89,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-20,NDC,outpatient,650,ME,11.57,8.099,AETNA [1000108],AETNA [100010801],,,76.8,,8.89,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,70954-0316-10,NDC,outpatient,50,ML,117.71,82.397,AETNA [1000108],AETNA [100010801],,,76.8,,90.4,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,99999-0004-18,NDC,outpatient,2.5,ML,4.86,3.402,AETNA [1000108],AETNA [100010801],,,76.8,,3.73,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,00904-7193-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,63739-0645-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,62332-0001-31,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FELBAMATE 600 MG ORAL TABS,RX-10025,CDM,S5000,HCPCS,259,RC,72578-0057-16,NDC,outpatient,1,UN,5.99,4.193,AETNA [1000108],AETNA [100010801],,,76.8,,4.6,0.222255,85118.57664,percent of total billed charges,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-61,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-06,NDC,outpatient,1,UN,1.66,1.162,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-01,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-11,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-15,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.222255,85118.57664,percent of total billed charges,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,00054-0011-21,NDC,outpatient,1,UN,2.98,2.086,AETNA [1000108],AETNA [100010801],,,76.8,,2.29,0.222255,85118.57664,percent of total billed charges,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-11,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.222255,85118.57664,percent of total billed charges,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-15,NDC,outpatient,1,UN,3.66,2.562,AETNA [1000108],AETNA [100010801],,,76.8,,2.81,0.222255,85118.57664,percent of total billed charges,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,00054-0010-20,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-11,NDC,outpatient,1,UN,3.66,2.562,AETNA [1000108],AETNA [100010801],,,76.8,,2.81,0.222255,85118.57664,percent of total billed charges,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-11,NDC,outpatient,1,UN,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-01,NDC,outpatient,1,UN,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,00904-6500-61,NDC,outpatient,1,UN,4.03,2.821,AETNA [1000108],AETNA [100010801],,,76.8,,3.1,0.222255,85118.57664,percent of total billed charges,
FLUCONAZOLE 200 MG ORAL TABS,RX-10045,CDM,S5000,HCPCS,259,RC,00904-6501-61,NDC,outpatient,1,UN,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-11,NDC,outpatient,1,UN,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.222255,85118.57664,percent of total billed charges,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,64380-0737-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-15,NDC,outpatient,1,UN,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.222255,85118.57664,percent of total billed charges,
FLUCYTOSINE 500 MG ORAL CAPS,RX-10052,CDM,S5000,HCPCS,259,RC,42794-0010-08,NDC,outpatient,1,UN,233.01,163.107,AETNA [1000108],AETNA [100010801],,,76.8,,178.95,0.222255,85118.57664,percent of total billed charges,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,00115-7033-01,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-11,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-15,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,16729-0542-35,NDC,outpatient,40,GR,458.18,320.726,AETNA [1000108],AETNA [100010801],,,76.8,,351.88,0.222255,85118.57664,percent of total billed charges,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,51672-4118-06,NDC,outpatient,40,GR,108.41,75.887,AETNA [1000108],AETNA [100010801],,,76.8,,83.26,0.222255,85118.57664,percent of total billed charges,
FLUOXETINE HCL 10 MG ORAL CAPS,RX-10069,CDM,S5000,HCPCS,259,RC,16714-0720-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FLUOXETINE HCL 20 MG ORAL CAPS,RX-10070,CDM,S5000,HCPCS,259,RC,00904-7346-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FLURBIPROFEN SODIUM 0.03 % OP SOLN,RX-10080,CDM,S5000,HCPCS,259,RC,69292-0722-25,NDC,outpatient,2.5,ML,140.89,98.623,AETNA [1000108],AETNA [100010801],,,76.8,,108.2,0.222255,85118.57664,percent of total billed charges,
FLUVOXAMINE MALEATE 50 MG ORAL TABS,RX-10085,CDM,S5000,HCPCS,259,RC,60505-0165-01,NDC,outpatient,1,UN,1.63,1.141,AETNA [1000108],AETNA [100010801],,,76.8,,1.25,0.222255,85118.57664,percent of total billed charges,
FOSINOPRIL SODIUM 10 MG ORAL TABS,RX-10094,CDM,S5000,HCPCS,259,RC,69097-0856-05,NDC,outpatient,1,UN,1.76,1.232,AETNA [1000108],AETNA [100010801],,,76.8,,1.35,0.222255,85118.57664,percent of total billed charges,
RITONAVIR 100 MG ORAL TABS,RX-100995,CDM,S5000,HCPCS,259,RC,00074-2340-30,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,0.222255,85118.57664,percent of total billed charges,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,00904-6637-61,NDC,outpatient,1,UN,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,60505-0141-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GLYBURIDE 2.5 MG ORAL TABS,RX-10126,CDM,S5000,HCPCS,259,RC,00093-8343-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GLYCOPYRROLATE 1 MG ORAL TABS,RX-10130,CDM,S5000,HCPCS,259,RC,23155-0606-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-62,NDC,outpatient,1,UN,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-59,NDC,outpatient,1,UN,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 500 MG ORAL TABS,RX-102,CDM,S5000,HCPCS,259,RC,00904-6730-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,59762-0073-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,64380-0970-25,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-07,NDC,outpatient,60,ML,88.11,61.677,AETNA [1000108],AETNA [100010801],,,76.8,,67.67,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-11,NDC,outpatient,60,ML,88.11,61.677,AETNA [1000108],AETNA [100010801],,,76.8,,67.67,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE MICRONIZED POWD,RX-10217,CDM,S5000,HCPCS,259,RC,51552-0020-05,NDC,outpatient,100,GR,1580.42,1106.294,AETNA [1000108],AETNA [100010801],,,76.8,,1213.76,0.222255,85118.57664,percent of total billed charges,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-01,NDC,outpatient,1,UN,4.87,3.409,AETNA [1000108],AETNA [100010801],,,76.8,,3.74,0.222255,85118.57664,percent of total billed charges,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-11,NDC,outpatient,1,UN,4.87,3.409,AETNA [1000108],AETNA [100010801],,,76.8,,3.74,0.222255,85118.57664,percent of total billed charges,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,00904-7046-61,NDC,outpatient,1,UN,3.27,2.289,AETNA [1000108],AETNA [100010801],,,76.8,,2.51,0.222255,85118.57664,percent of total billed charges,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-01,NDC,outpatient,1,UN,3.02,2.114,AETNA [1000108],AETNA [100010801],,,76.8,,2.32,0.222255,85118.57664,percent of total billed charges,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-11,NDC,outpatient,1,UN,3.02,2.114,AETNA [1000108],AETNA [100010801],,,76.8,,2.32,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,51672-2130-08,NDC,outpatient,120,ML,11.22,7.854,AETNA [1000108],AETNA [100010801],,,76.8,,8.62,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-47,NDC,outpatient,473,ML,67.36,47.152,AETNA [1000108],AETNA [100010801],,,76.8,,51.73,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,99999-0004-24,NDC,outpatient,5,ML,1.37,0.959,AETNA [1000108],AETNA [100010801],,,76.8,,1.05,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-05,NDC,outpatient,5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-00,NDC,outpatient,5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-59,NDC,outpatient,5,ML,2.54,1.778,AETNA [1000108],AETNA [100010801],,,76.8,,1.95,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-61,NDC,outpatient,5,ML,2.54,1.778,AETNA [1000108],AETNA [100010801],,,76.8,,1.95,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-62,NDC,outpatient,5,ML,2.59,1.813,AETNA [1000108],AETNA [100010801],,,76.8,,1.99,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-05,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-00,NDC,outpatient,5,ML,1398.02,978.614,AETNA [1000108],AETNA [100010801],,,76.8,,1073.68,0.222255,85118.57664,percent of total billed charges,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-05,NDC,outpatient,5,ML,1398.02,978.614,AETNA [1000108],AETNA [100010801],,,76.8,,1073.68,0.222255,85118.57664,percent of total billed charges,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-02,NDC,outpatient,1,UN,501.97,351.379,AETNA [1000108],AETNA [100010801],,,76.8,,385.51,0.222255,85118.57664,percent of total billed charges,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-01,NDC,outpatient,1,UN,501.97,351.379,AETNA [1000108],AETNA [100010801],,,76.8,,385.51,0.222255,85118.57664,percent of total billed charges,
INDOMETHACIN SODIUM 1 MG IV SOLR,RX-10267,CDM,S5000,HCPCS,250,RC,63323-0659-03,NDC,outpatient,1,UN,1192.43,834.701,AETNA [1000108],AETNA [100010801],,,76.8,,915.79,0.222255,85118.57664,percent of total billed charges,
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,S5000,HCPCS,259,RC,00002-8315-01,NDC,outpatient,10,ML,61.5,43.05,AETNA [1000108],AETNA [100010801],,,76.8,,47.23,0.222255,85118.57664,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,S5000,HCPCS,259,RC,00002-8215-01,NDC,outpatient,10,ML,61.5,43.05,AETNA [1000108],AETNA [100010801],,,76.8,,47.23,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,S5000,HCPCS,259,RC,45802-0732-30,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00713-0326-15,NDC,outpatient,15,GR,50.4,35.28,AETNA [1000108],AETNA [100010801],,,76.8,,38.71,0.222255,85118.57664,percent of total billed charges,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00472-0370-15,NDC,outpatient,15,GR,93.12,65.184,AETNA [1000108],AETNA [100010801],,,76.8,,71.52,0.222255,85118.57664,percent of total billed charges,
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,S5000,HCPCS,259,RC,00168-0041-60,NDC,outpatient,60,ML,267,186.9,AETNA [1000108],AETNA [100010801],,,76.8,,205.06,0.222255,85118.57664,percent of total billed charges,
ISOSORBIDE MONONITRATE 20 MG ORAL TABS,RX-10357,CDM,S5000,HCPCS,259,RC,00228-2620-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ISRADIPINE 5 MG ORAL CAPS,RX-10363,CDM,S5000,HCPCS,259,RC,16252-0540-01,NDC,outpatient,1,UN,8.59,6.013,AETNA [1000108],AETNA [100010801],,,76.8,,6.6,0.222255,85118.57664,percent of total billed charges,
ITRACONAZOLE 100 MG ORAL CAPS,RX-10364,CDM,S5000,HCPCS,259,RC,16714-0743-02,NDC,outpatient,1,UN,5.65,3.955,AETNA [1000108],AETNA [100010801],,,76.8,,4.34,0.222255,85118.57664,percent of total billed charges,
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,S5000,HCPCS,259,RC,00168-0099-15,NDC,outpatient,15,GR,22.57,15.799,AETNA [1000108],AETNA [100010801],,,76.8,,17.33,0.222255,85118.57664,percent of total billed charges,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,00093-0314-01,NDC,outpatient,1,UN,4.33,3.031,AETNA [1000108],AETNA [100010801],,,76.8,,3.33,0.222255,85118.57664,percent of total billed charges,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,70710-1710-01,NDC,outpatient,1,UN,3.63,2.541,AETNA [1000108],AETNA [100010801],,,76.8,,2.79,0.222255,85118.57664,percent of total billed charges,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-01,NDC,outpatient,1,UN,1.32,0.924,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-11,NDC,outpatient,1,UN,1.32,0.924,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-01,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-11,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,00904-5984-26,NDC,outpatient,226,GR,13.08,9.156,AETNA [1000108],AETNA [100010801],,,76.8,,10.05,0.222255,85118.57664,percent of total billed charges,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,16864-0000-18,NDC,outpatient,225,GR,41.06,28.742,AETNA [1000108],AETNA [100010801],,,76.8,,31.53,0.222255,85118.57664,percent of total billed charges,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,30781-7098-79,NDC,outpatient,225,GR,41.06,28.742,AETNA [1000108],AETNA [100010801],,,76.8,,31.53,0.222255,85118.57664,percent of total billed charges,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,51672-1300-05,NDC,outpatient,225,GR,61.08,42.756,AETNA [1000108],AETNA [100010801],,,76.8,,46.91,0.222255,85118.57664,percent of total billed charges,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,63044-0484-09,NDC,outpatient,225,GR,29.04,20.328,AETNA [1000108],AETNA [100010801],,,76.8,,22.3,0.222255,85118.57664,percent of total billed charges,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-11,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,57237-0014-01,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,72603-0115-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-01,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,63739-0567-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-02,NDC,outpatient,1,UN,2.7,1.89,AETNA [1000108],AETNA [100010801],,,76.8,,2.07,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-04,NDC,outpatient,1,UN,1.99,1.393,AETNA [1000108],AETNA [100010801],,,76.8,,1.53,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-20,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-01,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-11,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-01,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-01,NDC,outpatient,1,UN,2.79,1.953,AETNA [1000108],AETNA [100010801],,,76.8,,2.14,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-20,NDC,outpatient,1,UN,2.79,1.953,AETNA [1000108],AETNA [100010801],,,76.8,,2.14,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,69238-1835-01,NDC,outpatient,1,UN,1.64,1.148,AETNA [1000108],AETNA [100010801],,,76.8,,1.26,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00074-3727-90,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00378-1823-77,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00527-3287-46,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-20,NDC,outpatient,1,UN,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-01,NDC,outpatient,1,UN,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-12,NDC,outpatient,5,ML,4.55,3.185,AETNA [1000108],AETNA [100010801],,,76.8,,3.49,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0159-74,NDC,outpatient,5,ML,3.68,2.576,AETNA [1000108],AETNA [100010801],,,76.8,,2.83,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0163-30,NDC,outpatient,30,ML,6.17,4.319,AETNA [1000108],AETNA [100010801],,,76.8,,4.74,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-08,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-57,NDC,outpatient,5,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-25,NDC,outpatient,5,ML,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-02,NDC,outpatient,30,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-16,NDC,outpatient,30,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-26,NDC,outpatient,5,ML,4.55,3.185,AETNA [1000108],AETNA [100010801],,,76.8,,3.49,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-04,NDC,outpatient,2,ML,4.85,3.395,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-02,NDC,outpatient,5,ML,4.55,3.185,AETNA [1000108],AETNA [100010801],,,76.8,,3.49,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-27,NDC,outpatient,2,ML,4.85,3.395,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-97,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-01,NDC,outpatient,5,ML,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-09,NDC,outpatient,5,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-12,NDC,outpatient,10,ML,10.34,7.238,AETNA [1000108],AETNA [100010801],,,76.8,,7.94,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0165-05,NDC,outpatient,5,ML,4.63,3.241,AETNA [1000108],AETNA [100010801],,,76.8,,3.56,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-27,NDC,outpatient,2,ML,8.69,6.083,AETNA [1000108],AETNA [100010801],,,76.8,,6.67,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-03,NDC,outpatient,10,ML,28.48,19.936,AETNA [1000108],AETNA [100010801],,,76.8,,21.87,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-05,NDC,outpatient,5,ML,11.34,7.938,AETNA [1000108],AETNA [100010801],,,76.8,,8.71,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-11,NDC,outpatient,2,ML,4.57,3.199,AETNA [1000108],AETNA [100010801],,,76.8,,3.51,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-10,NDC,outpatient,5,ML,11.34,7.938,AETNA [1000108],AETNA [100010801],,,76.8,,8.71,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-01,NDC,outpatient,2,ML,4.57,3.199,AETNA [1000108],AETNA [100010801],,,76.8,,3.51,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-07,NDC,outpatient,5,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-09,NDC,outpatient,2,ML,8.69,6.083,AETNA [1000108],AETNA [100010801],,,76.8,,6.67,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-97,NDC,outpatient,10,ML,28.48,19.936,AETNA [1000108],AETNA [100010801],,,76.8,,21.87,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-01,NDC,outpatient,5,ML,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-25,NDC,outpatient,5,ML,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-02,NDC,outpatient,10,ML,10.34,7.238,AETNA [1000108],AETNA [100010801],,,76.8,,7.94,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-25,NDC,outpatient,2,ML,4.57,3.199,AETNA [1000108],AETNA [100010801],,,76.8,,3.51,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0164-02,NDC,outpatient,2,ML,4.16,2.912,AETNA [1000108],AETNA [100010801],,,76.8,,3.19,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-04,NDC,outpatient,5,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-57,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-16,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-16,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-17,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-03,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-17,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-27,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-02,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-07,NDC,outpatient,30,ML,30.31,21.217,AETNA [1000108],AETNA [100010801],,,76.8,,23.28,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-37,NDC,outpatient,30,ML,30.31,21.217,AETNA [1000108],AETNA [100010801],,,76.8,,23.28,0.222255,85118.57664,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-89,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-01,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-11,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-03,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-27,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-02,NDC,outpatient,20,ML,30.18,21.126,AETNA [1000108],AETNA [100010801],,,76.8,,23.18,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-01,NDC,outpatient,20,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-11,NDC,outpatient,20,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-17,NDC,outpatient,10,ML,19.13,13.391,AETNA [1000108],AETNA [100010801],,,76.8,,14.69,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-27,NDC,outpatient,20,ML,30.18,21.126,AETNA [1000108],AETNA [100010801],,,76.8,,23.18,0.222255,85118.57664,percent of total billed charges,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-89,NDC,outpatient,1,UN,2.51,1.757,AETNA [1000108],AETNA [100010801],,,76.8,,1.93,0.222255,85118.57664,percent of total billed charges,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-01,NDC,outpatient,1,UN,2.51,1.757,AETNA [1000108],AETNA [100010801],,,76.8,,1.93,0.222255,85118.57664,percent of total billed charges,
LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN,RX-10442,CDM,S5000,HCPCS,250,RC,39822-0151-01,NDC,outpatient,1,ML,1739.29,1217.503,AETNA [1000108],AETNA [100010801],,,76.8,,1335.77,0.222255,85118.57664,percent of total billed charges,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,00093-2179-01,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,68382-0582-01,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,00904-6798-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-03,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LISINOPRIL 5 MG ORAL TABS,RX-10451,CDM,S5000,HCPCS,259,RC,00904-6797-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-01,NDC,outpatient,1,UN,1.52,1.064,AETNA [1000108],AETNA [100010801],,,76.8,,1.17,0.222255,85118.57664,percent of total billed charges,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-11,NDC,outpatient,1,UN,1.52,1.064,AETNA [1000108],AETNA [100010801],,,76.8,,1.17,0.222255,85118.57664,percent of total billed charges,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-01,NDC,outpatient,1,UN,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-11,NDC,outpatient,1,UN,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68462-0224-01,NDC,outpatient,1,UN,1,0.7,AETNA [1000108],AETNA [100010801],,,76.8,,0.77,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-11,NDC,outpatient,1,UN,11.87,8.309,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,69918-0301-30,NDC,outpatient,1,UN,6.2,4.34,AETNA [1000108],AETNA [100010801],,,76.8,,4.76,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,62559-0265-30,NDC,outpatient,1,UN,10.97,7.679,AETNA [1000108],AETNA [100010801],,,76.8,,8.42,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-13,NDC,outpatient,1,UN,11.87,8.309,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-03,NDC,outpatient,1,UN,223.91,156.737,AETNA [1000108],AETNA [100010801],,,76.8,,171.96,0.222255,85118.57664,percent of total billed charges,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-02,NDC,outpatient,1,UN,223.91,156.737,AETNA [1000108],AETNA [100010801],,,76.8,,171.96,0.222255,85118.57664,percent of total billed charges,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,00904-6852-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,68382-0520-01,NDC,outpatient,1,UN,18.05,12.635,AETNA [1000108],AETNA [100010801],,,76.8,,13.86,0.222255,85118.57664,percent of total billed charges,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,59762-1001-01,NDC,outpatient,1,UN,20.25,14.175,AETNA [1000108],AETNA [100010801],,,76.8,,15.55,0.222255,85118.57664,percent of total billed charges,
MAFENIDE ACETATE 85 MG/GM EX CREA,RX-10478,CDM,S5000,HCPCS,259,RC,16571-0723-60,NDC,outpatient,56.7,GR,282.85,197.995,AETNA [1000108],AETNA [100010801],,,76.8,,217.23,0.222255,85118.57664,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,51754-0501-03,NDC,outpatient,3,ML,27.32,19.124,AETNA [1000108],AETNA [100010801],,,76.8,,20.98,0.222255,85118.57664,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-01,NDC,outpatient,3,ML,31.83,22.281,AETNA [1000108],AETNA [100010801],,,76.8,,24.45,0.222255,85118.57664,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-03,NDC,outpatient,3,ML,31.83,22.281,AETNA [1000108],AETNA [100010801],,,76.8,,24.45,0.222255,85118.57664,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,25021-0602-03,NDC,outpatient,3,ML,26.44,18.508,AETNA [1000108],AETNA [100010801],,,76.8,,20.31,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM OXIDE 140 MG ORAL CAPS,RX-10490,CDM,S5000,HCPCS,259,RC,60569-0495-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-30,NDC,outpatient,1,UN,1.95,1.365,AETNA [1000108],AETNA [100010801],,,76.8,,1.5,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-33,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-03,NDC,outpatient,946,ML,46.31,32.417,AETNA [1000108],AETNA [100010801],,,76.8,,35.57,0.222255,85118.57664,percent of total billed charges,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-13,NDC,outpatient,946,ML,46.31,32.417,AETNA [1000108],AETNA [100010801],,,76.8,,35.57,0.222255,85118.57664,percent of total billed charges,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-04,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-05,NDC,outpatient,15,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MESALAMINE ER 250 MG ORAL CPCR,RX-10533,CDM,S5000,HCPCS,259,RC,54092-0189-81,NDC,outpatient,1,UN,12.49,8.743,AETNA [1000108],AETNA [100010801],,,76.8,,9.59,0.222255,85118.57664,percent of total billed charges,
BROMOCRIPTINE MESYLATE 0.8 MG ORAL TABS,RX-105409,CDM,S5000,HCPCS,259,RC,68012-0258-20,NDC,outpatient,1,UN,23.23,16.261,AETNA [1000108],AETNA [100010801],,,76.8,,17.84,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,00904-7162-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,99999-0001-42,NDC,outpatient,20,ML,187.97,131.579,AETNA [1000108],AETNA [100010801],,,76.8,,144.36,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,00131-5410-72,NDC,outpatient,5,ML,47,32.9,AETNA [1000108],AETNA [100010801],,,76.8,,36.1,0.222255,85118.57664,percent of total billed charges,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-11,NDC,outpatient,1,UN,7.92,5.544,AETNA [1000108],AETNA [100010801],,,76.8,,6.08,0.222255,85118.57664,percent of total billed charges,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-21,NDC,outpatient,1,UN,7.92,5.544,AETNA [1000108],AETNA [100010801],,,76.8,,6.08,0.222255,85118.57664,percent of total billed charges,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-11,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,23155-0070-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-01,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-70,NDC,outpatient,10,ML,17.38,12.166,AETNA [1000108],AETNA [100010801],,,76.8,,13.35,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-02,NDC,outpatient,30,ML,28.84,20.188,AETNA [1000108],AETNA [100010801],,,76.8,,22.15,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-17,NDC,outpatient,10,ML,18.16,12.712,AETNA [1000108],AETNA [100010801],,,76.8,,13.95,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-30,NDC,outpatient,30,ML,36.85,25.795,AETNA [1000108],AETNA [100010801],,,76.8,,28.3,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-71,NDC,outpatient,30,ML,36.85,25.795,AETNA [1000108],AETNA [100010801],,,76.8,,28.3,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-01,NDC,outpatient,10,ML,18.15,12.705,AETNA [1000108],AETNA [100010801],,,76.8,,13.94,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-11,NDC,outpatient,10,ML,18.15,12.705,AETNA [1000108],AETNA [100010801],,,76.8,,13.94,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-10,NDC,outpatient,10,ML,17.38,12.166,AETNA [1000108],AETNA [100010801],,,76.8,,13.35,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-01,NDC,outpatient,10,ML,18.16,12.712,AETNA [1000108],AETNA [100010801],,,76.8,,13.95,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-37,NDC,outpatient,30,ML,28.84,20.188,AETNA [1000108],AETNA [100010801],,,76.8,,22.15,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-01,NDC,outpatient,10,ML,11.21,7.847,AETNA [1000108],AETNA [100010801],,,76.8,,8.61,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-04,NDC,outpatient,10,ML,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-31,NDC,outpatient,30,ML,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-37,NDC,outpatient,30,ML,30.98,21.686,AETNA [1000108],AETNA [100010801],,,76.8,,23.79,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-17,NDC,outpatient,30,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-16,NDC,outpatient,30,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-01,NDC,outpatient,30,ML,30.98,21.686,AETNA [1000108],AETNA [100010801],,,76.8,,23.79,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-11,NDC,outpatient,10,ML,11.21,7.847,AETNA [1000108],AETNA [100010801],,,76.8,,8.61,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-02,NDC,outpatient,30,ML,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-17,NDC,outpatient,10,ML,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-11,NDC,outpatient,1,UN,190.6,133.42,AETNA [1000108],AETNA [100010801],,,76.8,,146.38,0.222255,85118.57664,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-02,NDC,outpatient,1,UN,78.51,54.957,AETNA [1000108],AETNA [100010801],,,76.8,,60.3,0.222255,85118.57664,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-94,NDC,outpatient,1,UN,190.6,133.42,AETNA [1000108],AETNA [100010801],,,76.8,,146.38,0.222255,85118.57664,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-08,NDC,outpatient,1,UN,71.96,50.372,AETNA [1000108],AETNA [100010801],,,76.8,,55.27,0.222255,85118.57664,percent of total billed charges,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-20,NDC,outpatient,1,UN,11.25,7.875,AETNA [1000108],AETNA [100010801],,,76.8,,8.64,0.222255,85118.57664,percent of total billed charges,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-01,NDC,outpatient,1,UN,11.25,7.875,AETNA [1000108],AETNA [100010801],,,76.8,,8.64,0.222255,85118.57664,percent of total billed charges,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-20,NDC,outpatient,1,UN,12.79,8.953,AETNA [1000108],AETNA [100010801],,,76.8,,9.82,0.222255,85118.57664,percent of total billed charges,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-01,NDC,outpatient,1,UN,12.79,8.953,AETNA [1000108],AETNA [100010801],,,76.8,,9.82,0.222255,85118.57664,percent of total billed charges,
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,S5000,HCPCS,259,RC,16714-0557-01,NDC,outpatient,70,GR,66.67,46.669,AETNA [1000108],AETNA [100010801],,,76.8,,51.2,0.222255,85118.57664,percent of total billed charges,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,50742-0239-01,NDC,outpatient,1,UN,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,62559-0820-01,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,00093-8739-01,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
MEXILETINE HCL 200 MG ORAL CAPS,RX-10596,CDM,S5000,HCPCS,259,RC,00093-8740-01,NDC,outpatient,1,UN,3.1,2.17,AETNA [1000108],AETNA [100010801],,,76.8,,2.38,0.222255,85118.57664,percent of total billed charges,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,53329-0169-79,NDC,outpatient,85,GR,16.27,11.389,AETNA [1000108],AETNA [100010801],,,76.8,,12.5,0.222255,85118.57664,percent of total billed charges,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,11701-0038-16,NDC,outpatient,85,GR,25.73,18.011,AETNA [1000108],AETNA [100010801],,,76.8,,19.76,0.222255,85118.57664,percent of total billed charges,
MICROFIBRILLAR COLL HEMOSTAT EX PADS,RX-10605,CDM,S5000,HCPCS,259,RC,53276-1010-08,NDC,outpatient,1,UN,496.85,347.795,AETNA [1000108],AETNA [100010801],,,76.8,,381.58,0.222255,85118.57664,percent of total billed charges,
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,S5000,HCPCS,250,RC,53276-1010-02,NDC,outpatient,1,GR,993.69,695.583,AETNA [1000108],AETNA [100010801],,,76.8,,763.15,0.222255,85118.57664,percent of total billed charges,
ULIPRISTAL ACETATE 30 MG ORAL TABS,RX-106079,CDM,S5000,HCPCS,259,RC,73302-0456-01,NDC,outpatient,1,UN,159.36,111.552,AETNA [1000108],AETNA [100010801],,,76.8,,122.39,0.222255,85118.57664,percent of total billed charges,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00245-0211-11,NDC,outpatient,1,UN,1.99,1.393,AETNA [1000108],AETNA [100010801],,,76.8,,1.53,0.222255,85118.57664,percent of total billed charges,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00378-1901-01,NDC,outpatient,1,UN,2.12,1.484,AETNA [1000108],AETNA [100010801],,,76.8,,1.63,0.222255,85118.57664,percent of total billed charges,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,63739-0145-10,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-89,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-01,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00904-6818-61,NDC,outpatient,1,UN,2.24,1.568,AETNA [1000108],AETNA [100010801],,,76.8,,1.72,0.222255,85118.57664,percent of total billed charges,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-20,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-01,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-106248,CDM,S5000,HCPCS,259,RC,24208-0830-60,NDC,outpatient,5,ML,59.63,41.741,AETNA [1000108],AETNA [100010801],,,76.8,,45.8,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-106249,CDM,S5000,HCPCS,259,RC,61314-0631-36,NDC,outpatient,3.5,GR,69.78,48.846,AETNA [1000108],AETNA [100010801],,,76.8,,53.59,0.222255,85118.57664,percent of total billed charges,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,00025-1451-34,NDC,outpatient,1,UN,17.24,12.068,AETNA [1000108],AETNA [100010801],,,76.8,,13.24,0.222255,85118.57664,percent of total billed charges,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-01,NDC,outpatient,1,UN,9.27,6.489,AETNA [1000108],AETNA [100010801],,,76.8,,7.12,0.222255,85118.57664,percent of total billed charges,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-11,NDC,outpatient,1,UN,9.27,6.489,AETNA [1000108],AETNA [100010801],,,76.8,,7.12,0.222255,85118.57664,percent of total billed charges,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,59762-5007-01,NDC,outpatient,1,UN,2.08,1.456,AETNA [1000108],AETNA [100010801],,,76.8,,1.6,0.222255,85118.57664,percent of total billed charges,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-11,NDC,outpatient,1,UN,7.19,5.033,AETNA [1000108],AETNA [100010801],,,76.8,,5.52,0.222255,85118.57664,percent of total billed charges,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-01,NDC,outpatient,1,UN,7.19,5.033,AETNA [1000108],AETNA [100010801],,,76.8,,5.52,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-16,NDC,outpatient,50,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-01,NDC,outpatient,50,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.222255,85118.57664,percent of total billed charges,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-61,NDC,outpatient,1,UN,12.92,9.044,AETNA [1000108],AETNA [100010801],,,76.8,,9.92,0.222255,85118.57664,percent of total billed charges,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-56,NDC,outpatient,1,UN,12.92,9.044,AETNA [1000108],AETNA [100010801],,,76.8,,9.92,0.222255,85118.57664,percent of total billed charges,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-55,NDC,outpatient,1,UN,12.92,9.044,AETNA [1000108],AETNA [100010801],,,76.8,,9.92,0.222255,85118.57664,percent of total billed charges,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-82,NDC,outpatient,1,UN,12.92,9.044,AETNA [1000108],AETNA [100010801],,,76.8,,9.92,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,00406-8003-30,NDC,outpatient,0.25,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,99999-0002-18,NDC,outpatient,1,ML,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,45802-0112-22,NDC,outpatient,22,GR,13.61,9.527,AETNA [1000108],AETNA [100010801],,,76.8,,10.45,0.222255,85118.57664,percent of total billed charges,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,68462-0180-22,NDC,outpatient,22,GR,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,51672-1312-00,NDC,outpatient,22,GR,11.07,7.749,AETNA [1000108],AETNA [100010801],,,76.8,,8.5,0.222255,85118.57664,percent of total billed charges,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-11,NDC,outpatient,1,UN,3.85,2.695,AETNA [1000108],AETNA [100010801],,,76.8,,2.96,0.222255,85118.57664,percent of total billed charges,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-21,NDC,outpatient,1,UN,3.85,2.695,AETNA [1000108],AETNA [100010801],,,76.8,,2.96,0.222255,85118.57664,percent of total billed charges,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,00591-3670-01,NDC,outpatient,1,UN,1.2,0.84,AETNA [1000108],AETNA [100010801],,,76.8,,0.92,0.222255,85118.57664,percent of total billed charges,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-11,NDC,outpatient,1,UN,8.68,6.076,AETNA [1000108],AETNA [100010801],,,76.8,,6.67,0.222255,85118.57664,percent of total billed charges,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00904-7036-04,NDC,outpatient,1,UN,7.95,5.565,AETNA [1000108],AETNA [100010801],,,76.8,,6.11,0.222255,85118.57664,percent of total billed charges,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00406-1170-03,NDC,outpatient,1,UN,4.49,3.143,AETNA [1000108],AETNA [100010801],,,76.8,,3.45,0.222255,85118.57664,percent of total billed charges,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-21,NDC,outpatient,1,UN,8.68,6.076,AETNA [1000108],AETNA [100010801],,,76.8,,6.67,0.222255,85118.57664,percent of total billed charges,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,62559-0205-90,NDC,outpatient,1,UN,35.49,24.843,AETNA [1000108],AETNA [100010801],,,76.8,,27.26,0.222255,85118.57664,percent of total billed charges,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,68462-0120-90,NDC,outpatient,1,UN,18.98,13.286,AETNA [1000108],AETNA [100010801],,,76.8,,14.58,0.222255,85118.57664,percent of total billed charges,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,68462-0121-90,NDC,outpatient,1,UN,27.58,19.306,AETNA [1000108],AETNA [100010801],,,76.8,,21.18,0.222255,85118.57664,percent of total billed charges,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,42806-0502-09,NDC,outpatient,1,UN,24.73,17.311,AETNA [1000108],AETNA [100010801],,,76.8,,18.99,0.222255,85118.57664,percent of total billed charges,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-3029-23,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-1362-23,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00536-1372-23,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00135-0242-08,NDC,outpatient,1,UN,2.37,1.659,AETNA [1000108],AETNA [100010801],,,76.8,,1.82,0.222255,85118.57664,percent of total billed charges,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-00,NDC,outpatient,1,UN,5.11,3.577,AETNA [1000108],AETNA [100010801],,,76.8,,3.92,0.222255,85118.57664,percent of total billed charges,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-11,NDC,outpatient,1,UN,5.11,3.577,AETNA [1000108],AETNA [100010801],,,76.8,,3.92,0.222255,85118.57664,percent of total billed charges,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-15,NDC,outpatient,1,UN,7.34,5.138,AETNA [1000108],AETNA [100010801],,,76.8,,5.64,0.222255,85118.57664,percent of total billed charges,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,00904-7137-61,NDC,outpatient,1,UN,6.96,4.872,AETNA [1000108],AETNA [100010801],,,76.8,,5.35,0.222255,85118.57664,percent of total billed charges,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,16714-0439-01,NDC,outpatient,1,UN,7.17,5.019,AETNA [1000108],AETNA [100010801],,,76.8,,5.51,0.222255,85118.57664,percent of total billed charges,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-11,NDC,outpatient,1,UN,7.34,5.138,AETNA [1000108],AETNA [100010801],,,76.8,,5.64,0.222255,85118.57664,percent of total billed charges,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-01,NDC,outpatient,1,UN,9.67,6.769,AETNA [1000108],AETNA [100010801],,,76.8,,7.43,0.222255,85118.57664,percent of total billed charges,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-11,NDC,outpatient,1,UN,9.67,6.769,AETNA [1000108],AETNA [100010801],,,76.8,,7.43,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-04,NDC,outpatient,1,UN,146.92,102.844,AETNA [1000108],AETNA [100010801],,,76.8,,112.83,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-01,NDC,outpatient,1,UN,146.92,102.844,AETNA [1000108],AETNA [100010801],,,76.8,,112.83,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,42858-0750-40,NDC,outpatient,1,UN,220.77,154.539,AETNA [1000108],AETNA [100010801],,,76.8,,169.55,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-21,NDC,outpatient,1,UN,232.52,162.764,AETNA [1000108],AETNA [100010801],,,76.8,,178.58,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-40,NDC,outpatient,1,UN,232.52,162.764,AETNA [1000108],AETNA [100010801],,,76.8,,178.58,0.222255,85118.57664,percent of total billed charges,
OLSALAZINE SODIUM 250 MG ORAL CAPS,RX-10773,CDM,S5000,HCPCS,259,RC,00037-6860-10,NDC,outpatient,1,UN,61.39,42.973,AETNA [1000108],AETNA [100010801],,,76.8,,47.15,0.222255,85118.57664,percent of total billed charges,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-05,NDC,outpatient,5,ML,7.15,5.005,AETNA [1000108],AETNA [100010801],,,76.8,,5.49,0.222255,85118.57664,percent of total billed charges,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-40,NDC,outpatient,5,ML,7.15,5.005,AETNA [1000108],AETNA [100010801],,,76.8,,5.49,0.222255,85118.57664,percent of total billed charges,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-00,NDC,outpatient,5,ML,4.92,3.444,AETNA [1000108],AETNA [100010801],,,76.8,,3.78,0.222255,85118.57664,percent of total billed charges,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,99999-0001-41,NDC,outpatient,5,ML,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
BISACODYL 5 MG ORAL TBEC,RX-1079,CDM,S5000,HCPCS,259,RC,00904-6407-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-50,NDC,outpatient,1,UN,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-50,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,81421-0021-03,NDC,outpatient,1,UN,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-12,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-01,NDC,outpatient,2.5,GR,13.58,9.506,AETNA [1000108],AETNA [100010801],,,76.8,,10.43,0.222255,85118.57664,percent of total billed charges,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-02,NDC,outpatient,2.5,GR,13.58,9.506,AETNA [1000108],AETNA [100010801],,,76.8,,10.43,0.222255,85118.57664,percent of total billed charges,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-26,NDC,outpatient,5,GR,13.67,9.569,AETNA [1000108],AETNA [100010801],,,76.8,,10.5,0.222255,85118.57664,percent of total billed charges,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-30,NDC,outpatient,5,GR,13.67,9.569,AETNA [1000108],AETNA [100010801],,,76.8,,10.5,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,00406-8557-30,NDC,outpatient,30,ML,133.24,93.268,AETNA [1000108],AETNA [100010801],,,76.8,,102.33,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,99999-0002-27,NDC,outpatient,1,ML,7.21,5.047,AETNA [1000108],AETNA [100010801],,,76.8,,5.54,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-55,NDC,outpatient,5,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-05,NDC,outpatient,5,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00904-6966-61,NDC,outpatient,1,UN,1.01,0.707,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-62,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,42858-0001-10,NDC,outpatient,1,UN,1,0.7,AETNA [1000108],AETNA [100010801],,,76.8,,0.77,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,10702-0018-50,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-11,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-23,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,
PAROXETINE HCL 20 MG ORAL TABS,RX-10855,CDM,S5000,HCPCS,259,RC,63739-0963-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BISMUTH SUBCARBONATE POWD,RX-1086,CDM,S5000,HCPCS,259,RC,62991-2844-02,NDC,outpatient,100,GR,276.06,193.242,AETNA [1000108],AETNA [100010801],,,76.8,,212.01,0.222255,85118.57664,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,37000-0475-08,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,99999-0001-91,NDC,outpatient,30,ML,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
PERMETHRIN 5 % EX CREA,RX-10917,CDM,S5000,HCPCS,259,RC,00472-0242-60,NDC,outpatient,60,GR,76.37,53.459,AETNA [1000108],AETNA [100010801],,,76.8,,58.65,0.222255,85118.57664,percent of total billed charges,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-11,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.222255,85118.57664,percent of total billed charges,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-21,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.222255,85118.57664,percent of total billed charges,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00310-0095-30,NDC,outpatient,1,UN,54.75,38.325,AETNA [1000108],AETNA [100010801],,,76.8,,42.05,0.222255,85118.57664,percent of total billed charges,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00378-1905-77,NDC,outpatient,1,UN,17.44,12.208,AETNA [1000108],AETNA [100010801],,,76.8,,13.39,0.222255,85118.57664,percent of total billed charges,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,42571-0259-30,NDC,outpatient,1,UN,4.47,3.129,AETNA [1000108],AETNA [100010801],,,76.8,,3.43,0.222255,85118.57664,percent of total billed charges,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,31722-0623-90,NDC,outpatient,1,UN,7.15,5.005,AETNA [1000108],AETNA [100010801],,,76.8,,5.49,0.222255,85118.57664,percent of total billed charges,
PHENOXYBENZAMINE HCL 10 MG ORAL CAPS,RX-10945,CDM,S5000,HCPCS,259,RC,66993-0066-02,NDC,outpatient,1,UN,73.53,51.471,AETNA [1000108],AETNA [100010801],,,76.8,,56.47,0.222255,85118.57664,percent of total billed charges,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-10,NDC,outpatient,1,UN,1233.54,863.478,AETNA [1000108],AETNA [100010801],,,76.8,,947.36,0.222255,85118.57664,percent of total billed charges,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-01,NDC,outpatient,1,UN,1208.89,846.223,AETNA [1000108],AETNA [100010801],,,76.8,,928.43,0.222255,85118.57664,percent of total billed charges,
LINAGLIPTIN 5 MG ORAL TABS,RX-109773,CDM,S5000,HCPCS,259,RC,00597-0140-61,NDC,outpatient,1,UN,56.14,39.298,AETNA [1000108],AETNA [100010801],,,76.8,,43.12,0.222255,85118.57664,percent of total billed charges,
RILPIVIRINE HCL 25 MG ORAL TABS,RX-109909,CDM,S5000,HCPCS,259,RC,59676-0278-01,NDC,outpatient,1,UN,209.04,146.328,AETNA [1000108],AETNA [100010801],,,76.8,,160.54,0.222255,85118.57664,percent of total billed charges,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-25,NDC,outpatient,1,UN,4.05,2.835,AETNA [1000108],AETNA [100010801],,,76.8,,3.11,0.222255,85118.57664,percent of total billed charges,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,00904-7199-07,NDC,outpatient,1,UN,3.73,2.611,AETNA [1000108],AETNA [100010801],,,76.8,,2.86,0.222255,85118.57664,percent of total billed charges,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-95,NDC,outpatient,1,UN,4.05,2.835,AETNA [1000108],AETNA [100010801],,,76.8,,3.11,0.222255,85118.57664,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 30 MG ORAL CAPS,RX-11019,CDM,S5000,HCPCS,259,RC,00071-3740-66,NDC,outpatient,1,UN,5.97,4.179,AETNA [1000108],AETNA [100010801],,,76.8,,4.58,0.222255,85118.57664,percent of total billed charges,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-11,NDC,outpatient,1,UN,227.6,159.32,AETNA [1000108],AETNA [100010801],,,76.8,,174.8,0.222255,85118.57664,percent of total billed charges,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-94,NDC,outpatient,1,UN,227.6,159.32,AETNA [1000108],AETNA [100010801],,,76.8,,174.8,0.222255,85118.57664,percent of total billed charges,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FIDAXOMICIN 200 MG ORAL TABS,RX-110360,CDM,S5000,HCPCS,259,RC,52015-0080-01,NDC,outpatient,1,UN,501.77,351.239,AETNA [1000108],AETNA [100010801],,,76.8,,385.36,0.222255,85118.57664,percent of total billed charges,
TICAGRELOR 90 MG ORAL TABS,RX-110427,CDM,S5000,HCPCS,259,RC,00186-0777-39,NDC,outpatient,1,UN,30.77,21.539,AETNA [1000108],AETNA [100010801],,,76.8,,23.63,0.222255,85118.57664,percent of total billed charges,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00536-4306-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00904-2500-91,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG ORAL CAPS,RX-11050,CDM,S5000,HCPCS,259,RC,00904-5395-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,00178-0610-01,NDC,outpatient,1,UN,7.92,5.544,AETNA [1000108],AETNA [100010801],,,76.8,,6.08,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-32,NDC,outpatient,1,UN,8.47,5.929,AETNA [1000108],AETNA [100010801],,,76.8,,6.5,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-33,NDC,outpatient,1,UN,8.47,5.929,AETNA [1000108],AETNA [100010801],,,76.8,,6.5,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,68180-0678-01,NDC,outpatient,60,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,27241-0139-09,NDC,outpatient,60,ML,35.52,24.864,AETNA [1000108],AETNA [100010801],,,76.8,,27.28,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,99999-0000-41,NDC,outpatient,5,ML,52.63,36.841,AETNA [1000108],AETNA [100010801],,,76.8,,40.42,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,00004-0822-05,NDC,outpatient,60,ML,624.52,437.164,AETNA [1000108],AETNA [100010801],,,76.8,,479.63,0.222255,85118.57664,percent of total billed charges,
PRAVASTATIN SODIUM 10 MG ORAL TABS,RX-11110,CDM,S5000,HCPCS,259,RC,00904-5891-61,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,00904-5892-61,NDC,outpatient,1,UN,2.3,1.61,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.222255,85118.57664,percent of total billed charges,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-20,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-01,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-11,NDC,outpatient,1,UN,2.64,1.848,AETNA [1000108],AETNA [100010801],,,76.8,,2.03,0.222255,85118.57664,percent of total billed charges,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-01,NDC,outpatient,1,UN,2.64,1.848,AETNA [1000108],AETNA [100010801],,,76.8,,2.03,0.222255,85118.57664,percent of total billed charges,
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,S5000,HCPCS,259,RC,00574-7226-12,NDC,outpatient,1,UN,26.18,18.326,AETNA [1000108],AETNA [100010801],,,76.8,,20.11,0.222255,85118.57664,percent of total billed charges,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-12,NDC,outpatient,1,UN,43.38,30.366,AETNA [1000108],AETNA [100010801],,,76.8,,33.32,0.222255,85118.57664,percent of total billed charges,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-06,NDC,outpatient,1,UN,43.38,30.366,AETNA [1000108],AETNA [100010801],,,76.8,,33.32,0.222255,85118.57664,percent of total billed charges,
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,S5000,HCPCS,259,RC,00713-0526-12,NDC,outpatient,1,UN,43.38,30.366,AETNA [1000108],AETNA [100010801],,,76.8,,33.32,0.222255,85118.57664,percent of total billed charges,
PROPAFENONE HCL 150 MG ORAL TABS,RX-11146,CDM,S5000,HCPCS,259,RC,00591-0582-01,NDC,outpatient,1,UN,1.95,1.365,AETNA [1000108],AETNA [100010801],,,76.8,,1.5,0.222255,85118.57664,percent of total billed charges,
PROPAFENONE HCL 225 MG ORAL TABS,RX-11147,CDM,S5000,HCPCS,259,RC,00591-0583-01,NDC,outpatient,1,UN,1.32,0.924,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,00904-6622-61,NDC,outpatient,1,UN,3.64,2.548,AETNA [1000108],AETNA [100010801],,,76.8,,2.8,0.222255,85118.57664,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,68382-0659-06,NDC,outpatient,1,UN,1.59,1.113,AETNA [1000108],AETNA [100010801],,,76.8,,1.22,0.222255,85118.57664,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE ER 180 MG ORAL TBCR,RX-11240,CDM,S5000,HCPCS,259,RC,47781-0335-30,NDC,outpatient,1,UN,71.76,50.232,AETNA [1000108],AETNA [100010801],,,76.8,,55.11,0.222255,85118.57664,percent of total billed charges,
PYRIMETHAMINE 25 MG ORAL TABS,RX-11246,CDM,S5000,HCPCS,259,RC,43598-0672-01,NDC,outpatient,1,UN,1019.51,713.657,AETNA [1000108],AETNA [100010801],,,76.8,,782.98,0.222255,85118.57664,percent of total billed charges,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-05,NDC,outpatient,2,ML,92.93,65.051,AETNA [1000108],AETNA [100010801],,,76.8,,71.37,0.222255,85118.57664,percent of total billed charges,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-00,NDC,outpatient,2,ML,92.93,65.051,AETNA [1000108],AETNA [100010801],,,76.8,,71.37,0.222255,85118.57664,percent of total billed charges,
RAMIPRIL 1.25 MG ORAL CAPS,RX-11258,CDM,S5000,HCPCS,259,RC,68382-0144-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,57237-0224-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,68382-0146-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-21,NDC,outpatient,1,UN,9.33,6.531,AETNA [1000108],AETNA [100010801],,,76.8,,7.17,0.222255,85118.57664,percent of total billed charges,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,68180-0157-01,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-11,NDC,outpatient,1,UN,9.33,6.531,AETNA [1000108],AETNA [100010801],,,76.8,,7.17,0.222255,85118.57664,percent of total billed charges,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RIBAVIRIN 200 MG ORAL CAPS,RX-11286,CDM,S5000,HCPCS,259,RC,65862-0290-84,NDC,outpatient,1,UN,5.94,4.158,AETNA [1000108],AETNA [100010801],,,76.8,,4.56,0.222255,85118.57664,percent of total billed charges,
RIFABUTIN 150 MG ORAL CAPS,RX-11290,CDM,S5000,HCPCS,259,RC,59762-1350-01,NDC,outpatient,1,UN,47.58,33.306,AETNA [1000108],AETNA [100010801],,,76.8,,36.54,0.222255,85118.57664,percent of total billed charges,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,00068-0597-01,NDC,outpatient,1,UN,360.5,252.35,AETNA [1000108],AETNA [100010801],,,76.8,,276.86,0.222255,85118.57664,percent of total billed charges,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,67457-0445-60,NDC,outpatient,1,UN,242,169.4,AETNA [1000108],AETNA [100010801],,,76.8,,185.86,0.222255,85118.57664,percent of total billed charges,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,63323-0351-20,NDC,outpatient,1,UN,246.71,172.697,AETNA [1000108],AETNA [100010801],,,76.8,,189.47,0.222255,85118.57664,percent of total billed charges,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-11,NDC,outpatient,1,UN,10.17,7.119,AETNA [1000108],AETNA [100010801],,,76.8,,7.81,0.222255,85118.57664,percent of total billed charges,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-21,NDC,outpatient,1,UN,10.17,7.119,AETNA [1000108],AETNA [100010801],,,76.8,,7.81,0.222255,85118.57664,percent of total billed charges,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-01,NDC,outpatient,1,UN,6.25,4.375,AETNA [1000108],AETNA [100010801],,,76.8,,4.8,0.222255,85118.57664,percent of total billed charges,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-11,NDC,outpatient,1,UN,6.25,4.375,AETNA [1000108],AETNA [100010801],,,76.8,,4.8,0.222255,85118.57664,percent of total billed charges,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-01,NDC,outpatient,1,UN,9.15,6.405,AETNA [1000108],AETNA [100010801],,,76.8,,7.03,0.222255,85118.57664,percent of total billed charges,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-11,NDC,outpatient,1,UN,9.15,6.405,AETNA [1000108],AETNA [100010801],,,76.8,,7.03,0.222255,85118.57664,percent of total billed charges,
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-113082,CDM,S5000,HCPCS,259,RC,00487-5901-99,NDC,outpatient,1,UN,5.79,4.053,AETNA [1000108],AETNA [100010801],,,76.8,,4.45,0.222255,85118.57664,percent of total billed charges,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,65628-0070-03,NDC,outpatient,5,ML,27.75,19.425,AETNA [1000108],AETNA [100010801],,,76.8,,21.31,0.222255,85118.57664,percent of total billed charges,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,99999-9003-64,NDC,outpatient,5,ML,27.75,19.425,AETNA [1000108],AETNA [100010801],,,76.8,,21.31,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-04,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,76282-0213-18,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,00904-6925-61,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-01,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-11,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,68180-0352-09,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,63402-0302-30,NDC,outpatient,1,UN,165.29,115.703,AETNA [1000108],AETNA [100010801],,,76.8,,126.94,0.222255,85118.57664,percent of total billed charges,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,67877-0638-30,NDC,outpatient,1,UN,1.86,1.302,AETNA [1000108],AETNA [100010801],,,76.8,,1.43,0.222255,85118.57664,percent of total billed charges,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,16729-0346-10,NDC,outpatient,1,UN,5,3.5,AETNA [1000108],AETNA [100010801],,,76.8,,3.84,0.222255,85118.57664,percent of total billed charges,
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,S5000,HCPCS,259,RC,12870-0001-01,NDC,outpatient,10,UN,28.31,19.817,AETNA [1000108],AETNA [100010801],,,76.8,,21.74,0.222255,85118.57664,percent of total billed charges,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-30,NDC,outpatient,30,ML,19.63,13.741,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.222255,85118.57664,percent of total billed charges,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-00,NDC,outpatient,30,ML,19.63,13.741,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-04,NDC,outpatient,1000,ML,15.82,11.074,AETNA [1000108],AETNA [100010801],,,76.8,,12.15,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-03,NDC,outpatient,500,ML,11.87,8.309,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,S5000,HCPCS,259,RC,24208-0276-15,NDC,outpatient,15,ML,65.35,45.745,AETNA [1000108],AETNA [100010801],,,76.8,,50.19,0.222255,85118.57664,percent of total billed charges,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-11,NDC,outpatient,1,UN,4.36,3.052,AETNA [1000108],AETNA [100010801],,,76.8,,3.35,0.222255,85118.57664,percent of total billed charges,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-01,NDC,outpatient,1,UN,4.36,3.052,AETNA [1000108],AETNA [100010801],,,76.8,,3.35,0.222255,85118.57664,percent of total billed charges,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,29033-0003-05,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-01,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,59762-0401-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,62135-0436-90,NDC,outpatient,1,UN,16.45,11.515,AETNA [1000108],AETNA [100010801],,,76.8,,12.63,0.222255,85118.57664,percent of total billed charges,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,00093-2210-01,NDC,outpatient,1,UN,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-20,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,62559-0721-01,NDC,outpatient,1,UN,4.45,3.115,AETNA [1000108],AETNA [100010801],,,76.8,,3.42,0.222255,85118.57664,percent of total billed charges,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,00527-1318-01,NDC,outpatient,1,UN,19.38,13.566,AETNA [1000108],AETNA [100010801],,,76.8,,14.88,0.222255,85118.57664,percent of total billed charges,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-01,NDC,outpatient,2,ML,164.48,115.136,AETNA [1000108],AETNA [100010801],,,76.8,,126.32,0.222255,85118.57664,percent of total billed charges,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-10,NDC,outpatient,2,ML,164.48,115.136,AETNA [1000108],AETNA [100010801],,,76.8,,126.32,0.222255,85118.57664,percent of total billed charges,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-21,NDC,outpatient,1,UN,883.55,618.485,AETNA [1000108],AETNA [100010801],,,76.8,,678.57,0.222255,85118.57664,percent of total billed charges,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-22,NDC,outpatient,1,UN,883.55,618.485,AETNA [1000108],AETNA [100010801],,,76.8,,678.57,0.222255,85118.57664,percent of total billed charges,
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,S5000,HCPCS,250,RC,60793-0215-05,NDC,outpatient,1,UN,195.76,137.032,AETNA [1000108],AETNA [100010801],,,76.8,,150.34,0.222255,85118.57664,percent of total billed charges,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,60758-0802-05,NDC,outpatient,5,ML,11.17,7.819,AETNA [1000108],AETNA [100010801],,,76.8,,8.58,0.222255,85118.57664,percent of total billed charges,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,64980-0513-05,NDC,outpatient,5,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.222255,85118.57664,percent of total billed charges,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,60758-0801-05,NDC,outpatient,5,ML,22.48,15.736,AETNA [1000108],AETNA [100010801],,,76.8,,17.26,0.222255,85118.57664,percent of total billed charges,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,64980-0514-05,NDC,outpatient,5,ML,21.94,15.358,AETNA [1000108],AETNA [100010801],,,76.8,,16.85,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,S5000,HCPCS,259,RC,00078-0876-01,NDC,outpatient,3.5,GR,1115.32,780.724,AETNA [1000108],AETNA [100010801],,,76.8,,856.57,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,S5000,HCPCS,259,RC,24208-0295-25,NDC,outpatient,2.5,ML,173.64,121.548,AETNA [1000108],AETNA [100010801],,,76.8,,133.36,0.222255,85118.57664,percent of total billed charges,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,59212-0002-01,NDC,outpatient,1,UN,60.49,42.343,AETNA [1000108],AETNA [100010801],,,76.8,,46.46,0.222255,85118.57664,percent of total billed charges,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,66993-0831-02,NDC,outpatient,1,UN,36.58,25.606,AETNA [1000108],AETNA [100010801],,,76.8,,28.09,0.222255,85118.57664,percent of total billed charges,
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,S5000,HCPCS,259,RC,61314-0044-75,NDC,outpatient,7.5,ML,948.02,663.614,AETNA [1000108],AETNA [100010801],,,76.8,,728.08,0.222255,85118.57664,percent of total billed charges,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,24208-0315-10,NDC,outpatient,10,ML,47.84,33.488,AETNA [1000108],AETNA [100010801],,,76.8,,36.74,0.222255,85118.57664,percent of total billed charges,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,61314-0628-10,NDC,outpatient,10,ML,43.88,30.716,AETNA [1000108],AETNA [100010801],,,76.8,,33.7,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TABS,RX-11599,CDM,S5000,HCPCS,259,RC,00904-2725-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-01,NDC,outpatient,1,UN,15.37,10.759,AETNA [1000108],AETNA [100010801],,,76.8,,11.8,0.222255,85118.57664,percent of total billed charges,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-11,NDC,outpatient,1,UN,15.37,10.759,AETNA [1000108],AETNA [100010801],,,76.8,,11.8,0.222255,85118.57664,percent of total billed charges,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-01,NDC,outpatient,1,UN,11.52,8.064,AETNA [1000108],AETNA [100010801],,,76.8,,8.85,0.222255,85118.57664,percent of total billed charges,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-10,NDC,outpatient,1,UN,11.52,8.064,AETNA [1000108],AETNA [100010801],,,76.8,,8.85,0.222255,85118.57664,percent of total billed charges,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-01,NDC,outpatient,1,UN,41.49,29.043,AETNA [1000108],AETNA [100010801],,,76.8,,31.86,0.222255,85118.57664,percent of total billed charges,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-10,NDC,outpatient,1,UN,41.49,29.043,AETNA [1000108],AETNA [100010801],,,76.8,,31.86,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,RX-116728,CDM,S5000,HCPCS,259,RC,00597-0024-02,NDC,outpatient,4,GR,2012.08,1408.456,AETNA [1000108],AETNA [100010801],,,76.8,,1545.28,0.222255,85118.57664,percent of total billed charges,
ZIDOVUDINE 100 MG ORAL CAPS,RX-11692,CDM,S5000,HCPCS,259,RC,65862-0107-01,NDC,outpatient,1,UN,6.23,4.361,AETNA [1000108],AETNA [100010801],,,76.8,,4.78,0.222255,85118.57664,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRP,RX-11693,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,3.1,2.17,AETNA [1000108],AETNA [100010801],,,76.8,,2.38,0.222255,85118.57664,percent of total billed charges,
ZOLPIDEM TARTRATE 5 MG ORAL TABS,RX-11701,CDM,S5000,HCPCS,259,RC,00904-6082-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LINACLOTIDE 145 MCG ORAL CAPS,RX-117352,CDM,S5000,HCPCS,259,RC,00456-1201-30,NDC,outpatient,1,UN,74.11,51.877,AETNA [1000108],AETNA [100010801],,,76.8,,56.92,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-93,NDC,outpatient,1,UN,6.86,4.802,AETNA [1000108],AETNA [100010801],,,76.8,,5.27,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-01,NDC,outpatient,1,UN,8.83,6.181,AETNA [1000108],AETNA [100010801],,,76.8,,6.78,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-16,NDC,outpatient,1,UN,6.86,4.802,AETNA [1000108],AETNA [100010801],,,76.8,,5.27,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-07,NDC,outpatient,1,UN,8.83,6.181,AETNA [1000108],AETNA [100010801],,,76.8,,6.78,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-01,NDC,outpatient,1,UN,1.46,1.022,AETNA [1000108],AETNA [100010801],,,76.8,,1.12,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-62,NDC,outpatient,1,UN,4.35,3.045,AETNA [1000108],AETNA [100010801],,,76.8,,3.34,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-23,NDC,outpatient,1,UN,4.35,3.045,AETNA [1000108],AETNA [100010801],,,76.8,,3.34,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00904-6558-61,NDC,outpatient,1,UN,5.15,3.605,AETNA [1000108],AETNA [100010801],,,76.8,,3.96,0.222255,85118.57664,percent of total billed charges,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-21,NDC,outpatient,1,UN,6.17,4.319,AETNA [1000108],AETNA [100010801],,,76.8,,4.74,0.222255,85118.57664,percent of total billed charges,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-31,NDC,outpatient,1,UN,6.17,4.319,AETNA [1000108],AETNA [100010801],,,76.8,,4.74,0.222255,85118.57664,percent of total billed charges,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-01,NDC,outpatient,10,ML,102.35,71.645,AETNA [1000108],AETNA [100010801],,,76.8,,78.6,0.222255,85118.57664,percent of total billed charges,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-01,NDC,outpatient,10,ML,30.13,21.091,AETNA [1000108],AETNA [100010801],,,76.8,,23.14,0.222255,85118.57664,percent of total billed charges,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-10,NDC,outpatient,10,ML,30.13,21.091,AETNA [1000108],AETNA [100010801],,,76.8,,23.14,0.222255,85118.57664,percent of total billed charges,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-03,NDC,outpatient,10,ML,102.35,71.645,AETNA [1000108],AETNA [100010801],,,76.8,,78.6,0.222255,85118.57664,percent of total billed charges,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-11,NDC,outpatient,10,ML,30.26,21.182,AETNA [1000108],AETNA [100010801],,,76.8,,23.24,0.222255,85118.57664,percent of total billed charges,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-10,NDC,outpatient,10,ML,30.26,21.182,AETNA [1000108],AETNA [100010801],,,76.8,,23.24,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-62,NDC,outpatient,1,UN,2.2,1.54,AETNA [1000108],AETNA [100010801],,,76.8,,1.69,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-23,NDC,outpatient,1,UN,2.2,1.54,AETNA [1000108],AETNA [100010801],,,76.8,,1.69,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00228-4270-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,63304-0450-01,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-23,NDC,outpatient,1,UN,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-62,NDC,outpatient,1,UN,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-09,NDC,outpatient,10,ML,3.96,2.772,AETNA [1000108],AETNA [100010801],,,76.8,,3.04,0.222255,85118.57664,percent of total billed charges,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5649-01,NDC,outpatient,10,ML,39.65,27.755,AETNA [1000108],AETNA [100010801],,,76.8,,30.45,0.222255,85118.57664,percent of total billed charges,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-02,NDC,outpatient,10,ML,3.96,2.772,AETNA [1000108],AETNA [100010801],,,76.8,,3.04,0.222255,85118.57664,percent of total billed charges,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-28,NDC,outpatient,10,ML,3.96,2.772,AETNA [1000108],AETNA [100010801],,,76.8,,3.04,0.222255,85118.57664,percent of total billed charges,
APIXABAN 5 MG ORAL TABS,RX-119614,CDM,S5000,HCPCS,259,RC,00003-0894-31,NDC,outpatient,1,UN,6.17,4.319,AETNA [1000108],AETNA [100010801],,,76.8,,4.74,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,00023-5853-18,NDC,outpatient,1,UN,15.96,11.172,AETNA [1000108],AETNA [100010801],,,76.8,,12.26,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,59762-0117-01,NDC,outpatient,1,UN,10.4,7.28,AETNA [1000108],AETNA [100010801],,,76.8,,7.99,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-33,NDC,outpatient,1,UN,23.14,16.198,AETNA [1000108],AETNA [100010801],,,76.8,,17.77,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-32,NDC,outpatient,1,UN,23.14,16.198,AETNA [1000108],AETNA [100010801],,,76.8,,17.77,0.222255,85118.57664,percent of total billed charges,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-11,NDC,outpatient,1,UN,1.73,1.211,AETNA [1000108],AETNA [100010801],,,76.8,,1.33,0.222255,85118.57664,percent of total billed charges,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-01,NDC,outpatient,1,UN,1.73,1.211,AETNA [1000108],AETNA [100010801],,,76.8,,1.33,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,68462-0721-01,NDC,outpatient,1,UN,5.92,4.144,AETNA [1000108],AETNA [100010801],,,76.8,,4.55,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,62332-0025-31,NDC,outpatient,1,UN,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL ER 14 MG ORAL CP24,RX-121474,CDM,S5000,HCPCS,259,RC,00456-3414-33,NDC,outpatient,1,UN,7.56,5.292,AETNA [1000108],AETNA [100010801],,,76.8,,5.81,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL ER 21 MG ORAL CP24,RX-121475,CDM,S5000,HCPCS,259,RC,00456-3421-33,NDC,outpatient,1,UN,7.56,5.292,AETNA [1000108],AETNA [100010801],,,76.8,,5.81,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL ER 28 MG ORAL CP24,RX-121476,CDM,S5000,HCPCS,259,RC,00456-3428-33,NDC,outpatient,1,UN,63.71,44.597,AETNA [1000108],AETNA [100010801],,,76.8,,48.93,0.222255,85118.57664,percent of total billed charges,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,70505-0100-10,NDC,outpatient,1,UN,13.18,9.226,AETNA [1000108],AETNA [100010801],,,76.8,,10.12,0.222255,85118.57664,percent of total billed charges,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,55494-0100-10,NDC,outpatient,1,UN,13.41,9.387,AETNA [1000108],AETNA [100010801],,,76.8,,10.3,0.222255,85118.57664,percent of total billed charges,
QUINIDINE GLUCONATE ER 324 MG ORAL TBCR,RX-12197,CDM,S5000,HCPCS,259,RC,53489-0141-01,NDC,outpatient,1,UN,24.15,16.905,AETNA [1000108],AETNA [100010801],,,76.8,,18.55,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-25,NDC,outpatient,1,UN,3.98,2.786,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-95,NDC,outpatient,1,UN,3.98,2.786,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,57664-0395-88,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-01,NDC,outpatient,1,UN,3.02,2.114,AETNA [1000108],AETNA [100010801],,,76.8,,2.32,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-11,NDC,outpatient,1,UN,3.02,2.114,AETNA [1000108],AETNA [100010801],,,76.8,,2.32,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-01,NDC,outpatient,1,UN,2.34,1.638,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-11,NDC,outpatient,1,UN,2.34,1.638,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-39,NDC,outpatient,2.5,ML,560.63,392.441,AETNA [1000108],AETNA [100010801],,,76.8,,430.56,0.222255,85118.57664,percent of total billed charges,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-40,NDC,outpatient,2.5,ML,560.63,392.441,AETNA [1000108],AETNA [100010801],,,76.8,,430.56,0.222255,85118.57664,percent of total billed charges,
IRON-VITAMIN C 65-125 MG ORAL TABS,RX-122332,CDM,S5000,HCPCS,259,RC,63736-0123-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL ER 10 MG ORAL T12A,RX-122363,CDM,S5000,HCPCS,259,RC,59011-0410-20,NDC,outpatient,1,UN,22.52,15.764,AETNA [1000108],AETNA [100010801],,,76.8,,17.3,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-20,NDC,outpatient,1,UN,41.94,29.358,AETNA [1000108],AETNA [100010801],,,76.8,,32.21,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-10,NDC,outpatient,1,UN,40.9,28.63,AETNA [1000108],AETNA [100010801],,,76.8,,31.41,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL ER 40 MG ORAL T12A,RX-122368,CDM,S5000,HCPCS,259,RC,59011-0440-20,NDC,outpatient,1,UN,71.8,50.26,AETNA [1000108],AETNA [100010801],,,76.8,,55.14,0.222255,85118.57664,percent of total billed charges,
DOLUTEGRAVIR SODIUM 50 MG ORAL TABS,RX-122784,CDM,S5000,HCPCS,259,RC,49702-0228-13,NDC,outpatient,1,UN,324.81,227.367,AETNA [1000108],AETNA [100010801],,,76.8,,249.45,0.222255,85118.57664,percent of total billed charges,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,65162-0082-03,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,16729-0348-10,NDC,outpatient,1,UN,5,3.5,AETNA [1000108],AETNA [100010801],,,76.8,,3.84,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-04,NDC,outpatient,4,ML,17.02,11.914,AETNA [1000108],AETNA [100010801],,,76.8,,13.07,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-22,NDC,outpatient,4,ML,17.02,11.914,AETNA [1000108],AETNA [100010801],,,76.8,,13.07,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-01,NDC,outpatient,4,ML,26.92,18.844,AETNA [1000108],AETNA [100010801],,,76.8,,20.67,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-25,NDC,outpatient,4,ML,26.92,18.844,AETNA [1000108],AETNA [100010801],,,76.8,,20.67,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-60,NDC,outpatient,3,ML,9.75,6.825,AETNA [1000108],AETNA [100010801],,,76.8,,7.49,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-03,NDC,outpatient,30,ML,57.68,40.376,AETNA [1000108],AETNA [100010801],,,76.8,,44.3,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-11,NDC,outpatient,30,ML,57.68,40.376,AETNA [1000108],AETNA [100010801],,,76.8,,44.3,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-22,NDC,outpatient,30,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-30,NDC,outpatient,30,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.222255,85118.57664,percent of total billed charges,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-61,NDC,outpatient,3,ML,9.75,6.825,AETNA [1000108],AETNA [100010801],,,76.8,,7.49,0.222255,85118.57664,percent of total billed charges,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-42,NDC,outpatient,2,ML,21.6,15.12,AETNA [1000108],AETNA [100010801],,,76.8,,16.59,0.222255,85118.57664,percent of total billed charges,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-03,NDC,outpatient,2,ML,9.94,6.958,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,0.222255,85118.57664,percent of total billed charges,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-03,NDC,outpatient,2,ML,11.79,8.253,AETNA [1000108],AETNA [100010801],,,76.8,,9.05,0.222255,85118.57664,percent of total billed charges,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-02,NDC,outpatient,2,ML,21.6,15.12,AETNA [1000108],AETNA [100010801],,,76.8,,16.59,0.222255,85118.57664,percent of total billed charges,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-41,NDC,outpatient,2,ML,9.94,6.958,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,0.222255,85118.57664,percent of total billed charges,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-02,NDC,outpatient,2,ML,11.79,8.253,AETNA [1000108],AETNA [100010801],,,76.8,,9.05,0.222255,85118.57664,percent of total billed charges,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,51672-4070-08,NDC,outpatient,2.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,99999-0004-13,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,70069-0131-01,NDC,outpatient,5,ML,22.25,15.575,AETNA [1000108],AETNA [100010801],,,76.8,,17.09,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,61314-0643-05,NDC,outpatient,5,ML,42.15,29.505,AETNA [1000108],AETNA [100010801],,,76.8,,32.37,0.222255,85118.57664,percent of total billed charges,
EXENATIDE 5 MCG/0.02ML SC SOPN,RX-124738,CDM,S5000,HCPCS,259,RC,00310-6512-01,NDC,outpatient,1.2,ML,2102.55,1471.785,AETNA [1000108],AETNA [100010801],,,76.8,,1614.76,0.222255,85118.57664,percent of total billed charges,
EXENATIDE 10 MCG/0.04ML SC SOPN,RX-124739,CDM,S5000,HCPCS,259,RC,00310-6524-01,NDC,outpatient,2.4,ML,2102.55,1471.785,AETNA [1000108],AETNA [100010801],,,76.8,,1614.76,0.222255,85118.57664,percent of total billed charges,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-12,NDC,outpatient,3,ML,1117.4,782.18,AETNA [1000108],AETNA [100010801],,,76.8,,858.16,0.222255,85118.57664,percent of total billed charges,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-13,NDC,outpatient,3,ML,1117.41,782.187,AETNA [1000108],AETNA [100010801],,,76.8,,858.17,0.222255,85118.57664,percent of total billed charges,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,00555-0899-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,42806-0087-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN 0.3 % OP OINT,RX-125351,CDM,S5000,HCPCS,259,RC,00078-0813-01,NDC,outpatient,3.5,GR,1047.63,733.341,AETNA [1000108],AETNA [100010801],,,76.8,,804.58,0.222255,85118.57664,percent of total billed charges,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL LIQD,RX-12556,CDM,S5000,HCPCS,259,RC,00904-6985-20,NDC,outpatient,2.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-83,NDC,outpatient,2.5,ML,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-79,NDC,outpatient,2.5,ML,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,76204-0100-01,NDC,outpatient,2.5,ML,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00378-7970-93,NDC,outpatient,2.5,ML,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-01,NDC,outpatient,2.5,ML,1.51,1.057,AETNA [1000108],AETNA [100010801],,,76.8,,1.16,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-60,NDC,outpatient,2.5,ML,1.12,0.784,AETNA [1000108],AETNA [100010801],,,76.8,,0.86,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-125849,CDM,S5000,HCPCS,259,RC,00536-1186-12,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CAFFEINE 200 MG ORAL TABS,RX-1259,CDM,S5000,HCPCS,259,RC,46017-0018-40,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DANTROLENE SODIUM 250 MG IV SUSR,RX-126042,CDM,S5000,HCPCS,250,RC,42367-0540-32,NDC,outpatient,1,UN,5868.29,4107.803,AETNA [1000108],AETNA [100010801],,,76.8,,4506.85,0.222255,85118.57664,percent of total billed charges,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-30,NDC,outpatient,1,UN,55.29,38.703,AETNA [1000108],AETNA [100010801],,,76.8,,42.46,0.222255,85118.57664,percent of total billed charges,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-37,NDC,outpatient,1,UN,55.29,38.703,AETNA [1000108],AETNA [100010801],,,76.8,,42.46,0.222255,85118.57664,percent of total billed charges,
EMPAGLIFLOZIN 25 MG ORAL TABS,RX-126078,CDM,S5000,HCPCS,259,RC,00597-0153-37,NDC,outpatient,1,UN,55.29,38.703,AETNA [1000108],AETNA [100010801],,,76.8,,42.46,0.222255,85118.57664,percent of total billed charges,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-10,NDC,outpatient,2,ML,107.33,75.131,AETNA [1000108],AETNA [100010801],,,76.8,,82.43,0.222255,85118.57664,percent of total billed charges,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-01,NDC,outpatient,2,ML,107.33,75.131,AETNA [1000108],AETNA [100010801],,,76.8,,82.43,0.222255,85118.57664,percent of total billed charges,
TERBINAFINE HCL 250 MG ORAL TABS,RX-12724,CDM,S5000,HCPCS,259,RC,65862-0079-30,NDC,outpatient,1,UN,1.29,0.903,AETNA [1000108],AETNA [100010801],,,76.8,,0.99,0.222255,85118.57664,percent of total billed charges,
TRIAMTERENE-HCTZ 37.5-25 MG ORAL CAPS,RX-12729,CDM,S5000,HCPCS,259,RC,00781-2074-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE IN NACL 20-0.9 MG/50ML-% IV SOLN,RX-12735,CDM,S5000,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,AETNA [1000108],AETNA [100010801],,,76.8,,18.61,0.222255,85118.57664,percent of total billed charges,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,99999-0002-29,NDC,outpatient,5,ML,70.67,49.469,AETNA [1000108],AETNA [100010801],,,76.8,,54.27,0.222255,85118.57664,percent of total billed charges,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-05,NDC,outpatient,5,ML,13.49,9.443,AETNA [1000108],AETNA [100010801],,,76.8,,10.36,0.222255,85118.57664,percent of total billed charges,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-04,NDC,outpatient,5,ML,45.71,31.997,AETNA [1000108],AETNA [100010801],,,76.8,,35.11,0.222255,85118.57664,percent of total billed charges,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-04,NDC,outpatient,5,ML,13.49,9.443,AETNA [1000108],AETNA [100010801],,,76.8,,10.36,0.222255,85118.57664,percent of total billed charges,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-05,NDC,outpatient,5,ML,45.71,31.997,AETNA [1000108],AETNA [100010801],,,76.8,,35.11,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HR TD PTWK,RX-127562,CDM,S5000,HCPCS,259,RC,42858-0353-40,NDC,outpatient,1,UN,309.07,216.349,AETNA [1000108],AETNA [100010801],,,76.8,,237.37,0.222255,85118.57664,percent of total billed charges,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,00527-1313-01,NDC,outpatient,1,UN,4.2,2.94,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-25,NDC,outpatient,1,UN,10.51,7.357,AETNA [1000108],AETNA [100010801],,,76.8,,8.07,0.222255,85118.57664,percent of total billed charges,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-95,NDC,outpatient,1,UN,10.51,7.357,AETNA [1000108],AETNA [100010801],,,76.8,,8.07,0.222255,85118.57664,percent of total billed charges,
TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,RX-128423,CDM,S5000,HCPCS,259,RC,00597-0100-51,NDC,outpatient,4,GR,308.39,215.873,AETNA [1000108],AETNA [100010801],,,76.8,,236.84,0.222255,85118.57664,percent of total billed charges,
PENTOSAN POLYSULFATE SODIUM 100 MG ORAL CAPS,RX-12912,CDM,S5000,HCPCS,259,RC,50458-0098-01,NDC,outpatient,1,UN,46.46,32.522,AETNA [1000108],AETNA [100010801],,,76.8,,35.68,0.222255,85118.57664,percent of total billed charges,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-20,NDC,outpatient,1,UN,4.95,3.465,AETNA [1000108],AETNA [100010801],,,76.8,,3.8,0.222255,85118.57664,percent of total billed charges,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-01,NDC,outpatient,1,UN,4.95,3.465,AETNA [1000108],AETNA [100010801],,,76.8,,3.8,0.222255,85118.57664,percent of total billed charges,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,00904-7097-61,NDC,outpatient,1,UN,4.43,3.101,AETNA [1000108],AETNA [100010801],,,76.8,,3.4,0.222255,85118.57664,percent of total billed charges,
DOMEBORO EX PACK,RX-129475,CDM,S5000,HCPCS,259,RC,57074-0001-77,NDC,outpatient,1,UN,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,
DARUNAVIR-COBICISTAT 800-150 MG ORAL TABS,RX-129730,CDM,S5000,HCPCS,259,RC,59676-0575-30,NDC,outpatient,1,UN,354.92,248.444,AETNA [1000108],AETNA [100010801],,,76.8,,272.58,0.222255,85118.57664,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-72,NDC,outpatient,2,ML,130.52,91.364,AETNA [1000108],AETNA [100010801],,,76.8,,100.24,0.222255,85118.57664,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-95,NDC,outpatient,2,ML,130.52,91.364,AETNA [1000108],AETNA [100010801],,,76.8,,100.24,0.222255,85118.57664,percent of total billed charges,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-04,NDC,outpatient,1,UN,23.54,16.478,AETNA [1000108],AETNA [100010801],,,76.8,,18.08,0.222255,85118.57664,percent of total billed charges,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-90,NDC,outpatient,1,UN,23.54,16.478,AETNA [1000108],AETNA [100010801],,,76.8,,18.08,0.222255,85118.57664,percent of total billed charges,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-01,NDC,outpatient,1,UN,42.28,29.596,AETNA [1000108],AETNA [100010801],,,76.8,,32.47,0.222255,85118.57664,percent of total billed charges,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-24,NDC,outpatient,1,UN,23.2,16.24,AETNA [1000108],AETNA [100010801],,,76.8,,17.82,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-10,NDC,outpatient,4,ML,15.67,10.969,AETNA [1000108],AETNA [100010801],,,76.8,,12.03,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-14,NDC,outpatient,4,ML,23.45,16.415,AETNA [1000108],AETNA [100010801],,,76.8,,18.01,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-00,NDC,outpatient,4,ML,24.37,17.059,AETNA [1000108],AETNA [100010801],,,76.8,,18.72,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-01,NDC,outpatient,4,ML,15.67,10.969,AETNA [1000108],AETNA [100010801],,,76.8,,12.03,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-04,NDC,outpatient,4,ML,23.45,16.415,AETNA [1000108],AETNA [100010801],,,76.8,,18.01,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-01,NDC,outpatient,4,ML,19.72,13.804,AETNA [1000108],AETNA [100010801],,,76.8,,15.14,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-07,NDC,outpatient,4,ML,19.72,13.804,AETNA [1000108],AETNA [100010801],,,76.8,,15.14,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,25021-0316-04,NDC,outpatient,4,ML,19.53,13.671,AETNA [1000108],AETNA [100010801],,,76.8,,15,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-04,NDC,outpatient,4,ML,24.37,17.059,AETNA [1000108],AETNA [100010801],,,76.8,,18.72,0.222255,85118.57664,percent of total billed charges,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,00904-3232-92,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,20555-0005-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,00536-1202-07,NDC,outpatient,1,UN,3.11,2.177,AETNA [1000108],AETNA [100010801],,,76.8,,2.39,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,41167-0058-40,NDC,outpatient,1,UN,6.13,4.291,AETNA [1000108],AETNA [100010801],,,76.8,,4.71,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,70512-0812-30,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,59762-1210-03,NDC,outpatient,1,UN,2.76,1.932,AETNA [1000108],AETNA [100010801],,,76.8,,2.12,0.222255,85118.57664,percent of total billed charges,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,68180-0604-06,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-11,NDC,outpatient,10,ML,55.67,38.969,AETNA [1000108],AETNA [100010801],,,76.8,,42.75,0.222255,85118.57664,percent of total billed charges,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-40,NDC,outpatient,10,ML,41.92,29.344,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.222255,85118.57664,percent of total billed charges,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-10,NDC,outpatient,10,ML,41.92,29.344,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.222255,85118.57664,percent of total billed charges,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-34,NDC,outpatient,10,ML,55.67,38.969,AETNA [1000108],AETNA [100010801],,,76.8,,42.75,0.222255,85118.57664,percent of total billed charges,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,76329-3304-01,NDC,outpatient,10,ML,39.08,27.356,AETNA [1000108],AETNA [100010801],,,76.8,,30.01,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-01,NDC,outpatient,1,UN,5.2,3.64,AETNA [1000108],AETNA [100010801],,,76.8,,3.99,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-11,NDC,outpatient,1,UN,5.2,3.64,AETNA [1000108],AETNA [100010801],,,76.8,,3.99,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,68462-0260-01,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-131078,CDM,S5000,HCPCS,259,RC,00597-0155-70,NDC,outpatient,4,GR,308.39,215.873,AETNA [1000108],AETNA [100010801],,,76.8,,236.84,0.222255,85118.57664,percent of total billed charges,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,00904-5823-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG ORAL TABS,RX-131233,CDM,S5000,HCPCS,259,RC,61958-1901-01,NDC,outpatient,1,UN,572.84,400.988,AETNA [1000108],AETNA [100010801],,,76.8,,439.94,0.222255,85118.57664,percent of total billed charges,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,00904-6565-61,NDC,outpatient,1,UN,4.32,3.024,AETNA [1000108],AETNA [100010801],,,76.8,,3.32,0.222255,85118.57664,percent of total billed charges,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,63739-0077-10,NDC,outpatient,1,UN,4,2.8,AETNA [1000108],AETNA [100010801],,,76.8,,3.07,0.222255,85118.57664,percent of total billed charges,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-11,NDC,outpatient,1,UN,4.3,3.01,AETNA [1000108],AETNA [100010801],,,76.8,,3.3,0.222255,85118.57664,percent of total billed charges,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-01,NDC,outpatient,1,UN,4.3,3.01,AETNA [1000108],AETNA [100010801],,,76.8,,3.3,0.222255,85118.57664,percent of total billed charges,
SACUBITRIL-VALSARTAN 24-26 MG ORAL TABS,RX-131630,CDM,S5000,HCPCS,259,RC,00078-0659-20,NDC,outpatient,1,UN,46.68,32.676,AETNA [1000108],AETNA [100010801],,,76.8,,35.85,0.222255,85118.57664,percent of total billed charges,
SACUBITRIL-VALSARTAN 49-51 MG ORAL TABS,RX-131631,CDM,S5000,HCPCS,259,RC,00078-0777-20,NDC,outpatient,1,UN,46.68,32.676,AETNA [1000108],AETNA [100010801],,,76.8,,35.85,0.222255,85118.57664,percent of total billed charges,
SACUBITRIL-VALSARTAN 97-103 MG ORAL TABS,RX-131632,CDM,S5000,HCPCS,259,RC,00078-0696-20,NDC,outpatient,1,UN,46.68,32.676,AETNA [1000108],AETNA [100010801],,,76.8,,35.85,0.222255,85118.57664,percent of total billed charges,
AMINOCAPROIC ACID 0.25 GM/ML ORAL SOLN,RX-131645,CDM,S5000,HCPCS,259,RC,99999-0001-90,NDC,outpatient,5,ML,202.39,141.673,AETNA [1000108],AETNA [100010801],,,76.8,,155.44,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL ER 120 MG ORAL TBCR,RX-13184,CDM,S5000,HCPCS,259,RC,68462-0292-01,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE (PF) 0.75% -1:200000 IJ SOLN,RX-132205,CDM,S5000,HCPCS,250,RC,63323-0460-37,NDC,outpatient,30,ML,34.71,24.297,AETNA [1000108],AETNA [100010801],,,76.8,,26.66,0.222255,85118.57664,percent of total billed charges,
TICAGRELOR 60 MG ORAL TABS,RX-132286,CDM,S5000,HCPCS,259,RC,00186-0776-60,NDC,outpatient,1,UN,30.77,21.539,AETNA [1000108],AETNA [100010801],,,76.8,,23.63,0.222255,85118.57664,percent of total billed charges,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,69374-0982-55,NDC,outpatient,5,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-9119-44,NDC,outpatient,5,ML,27.82,19.474,AETNA [1000108],AETNA [100010801],,,76.8,,21.37,0.222255,85118.57664,percent of total billed charges,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70004-0430-09,NDC,outpatient,5,ML,28.93,20.251,AETNA [1000108],AETNA [100010801],,,76.8,,22.22,0.222255,85118.57664,percent of total billed charges,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-1119-44,NDC,outpatient,5,ML,20.39,14.273,AETNA [1000108],AETNA [100010801],,,76.8,,15.66,0.222255,85118.57664,percent of total billed charges,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,00904-7119-06,NDC,outpatient,1,UN,3.29,2.303,AETNA [1000108],AETNA [100010801],,,76.8,,2.53,0.222255,85118.57664,percent of total billed charges,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-01,NDC,outpatient,1,UN,5.45,3.815,AETNA [1000108],AETNA [100010801],,,76.8,,4.19,0.222255,85118.57664,percent of total billed charges,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-11,NDC,outpatient,1,UN,5.45,3.815,AETNA [1000108],AETNA [100010801],,,76.8,,4.19,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-01,NDC,outpatient,1,UN,29.34,20.538,AETNA [1000108],AETNA [100010801],,,76.8,,22.53,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-60,NDC,outpatient,1,UN,29.34,20.538,AETNA [1000108],AETNA [100010801],,,76.8,,22.53,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-01,NDC,outpatient,1,UN,46.07,32.249,AETNA [1000108],AETNA [100010801],,,76.8,,35.38,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-60,NDC,outpatient,1,UN,46.07,32.249,AETNA [1000108],AETNA [100010801],,,76.8,,35.38,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-60,NDC,outpatient,1,UN,70.24,49.168,AETNA [1000108],AETNA [100010801],,,76.8,,53.94,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-01,NDC,outpatient,1,UN,70.24,49.168,AETNA [1000108],AETNA [100010801],,,76.8,,53.94,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-60,NDC,outpatient,1,UN,72.31,50.617,AETNA [1000108],AETNA [100010801],,,76.8,,55.53,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-01,NDC,outpatient,1,UN,72.31,50.617,AETNA [1000108],AETNA [100010801],,,76.8,,55.53,0.222255,85118.57664,percent of total billed charges,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.222255,85118.57664,percent of total billed charges,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.222255,85118.57664,percent of total billed charges,
PRENATAL VITAMIN PLUS LOW IRON 27-1 MG ORAL TABS,RX-133380,CDM,S5000,HCPCS,259,RC,39328-0106-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FAMCICLOVIR 500 MG ORAL TABS,RX-13358,CDM,S5000,HCPCS,259,RC,60505-3247-03,NDC,outpatient,1,UN,1.93,1.351,AETNA [1000108],AETNA [100010801],,,76.8,,1.48,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,AETNA [1000108],AETNA [100010801],,,76.8,,18.32,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,14.6,10.22,AETNA [1000108],AETNA [100010801],,,76.8,,11.21,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,14.6,10.22,AETNA [1000108],AETNA [100010801],,,76.8,,11.21,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-01,NDC,outpatient,3,ML,1168.7,818.09,AETNA [1000108],AETNA [100010801],,,76.8,,897.56,0.222255,85118.57664,percent of total billed charges,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-27,NDC,outpatient,3,ML,1168.7,818.09,AETNA [1000108],AETNA [100010801],,,76.8,,897.56,0.222255,85118.57664,percent of total billed charges,
EMTRICITABINE-TENOFOVIR AF 200-25 MG ORAL TABS,RX-134420,CDM,S5000,HCPCS,259,RC,61958-2002-01,NDC,outpatient,1,UN,316.88,221.816,AETNA [1000108],AETNA [100010801],,,76.8,,243.36,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70004-0540-35,NDC,outpatient,125,ML,123.38,86.366,AETNA [1000108],AETNA [100010801],,,76.8,,94.76,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1007-36,NDC,outpatient,125,ML,77.9,54.53,AETNA [1000108],AETNA [100010801],,,76.8,,59.83,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1575-36,NDC,outpatient,125,ML,81.02,56.714,AETNA [1000108],AETNA [100010801],,,76.8,,62.22,0.222255,85118.57664,percent of total billed charges,
PSYLLIUM 400 MG ORAL CAPS,RX-134482,CDM,S5000,HCPCS,259,RC,37000-0405-14,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,00904-3854-61,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-01,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-11,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE 100 MG/5ML ORAL SUSP,RX-1356,CDM,S5000,HCPCS,259,RC,99999-0001-92,NDC,outpatient,10,ML,6.06,4.242,AETNA [1000108],AETNA [100010801],,,76.8,,4.65,0.222255,85118.57664,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-05,NDC,outpatient,10,ML,411.18,287.826,AETNA [1000108],AETNA [100010801],,,76.8,,315.79,0.222255,85118.57664,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-01,NDC,outpatient,10,ML,411.18,287.826,AETNA [1000108],AETNA [100010801],,,76.8,,315.79,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE 200 MG ORAL TABS,RX-1357,CDM,S5000,HCPCS,259,RC,00904-6172-61,NDC,outpatient,1,UN,2.42,1.694,AETNA [1000108],AETNA [100010801],,,76.8,,1.86,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70004-0725-05,NDC,outpatient,1,ML,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70092-1443-43,NDC,outpatient,1,ML,22.08,15.456,AETNA [1000108],AETNA [100010801],,,76.8,,16.96,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,99999-0003-11,NDC,outpatient,1.1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70004-0924-59,NDC,outpatient,280,ML,189.24,132.468,AETNA [1000108],AETNA [100010801],,,76.8,,145.34,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,99999-0001-84,NDC,outpatient,280,ML,33.42,23.394,AETNA [1000108],AETNA [100010801],,,76.8,,25.67,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70092-9056-05,NDC,outpatient,280,ML,121.34,84.938,AETNA [1000108],AETNA [100010801],,,76.8,,93.19,0.222255,85118.57664,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,00904-6627-35,NDC,outpatient,15,ML,6.35,4.445,AETNA [1000108],AETNA [100010801],,,76.8,,4.88,0.222255,85118.57664,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-23,NDC,outpatient,15,ML,15.56,10.892,AETNA [1000108],AETNA [100010801],,,76.8,,11.95,0.222255,85118.57664,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-21,NDC,outpatient,15,ML,17.89,12.523,AETNA [1000108],AETNA [100010801],,,76.8,,13.74,0.222255,85118.57664,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-15,NDC,outpatient,1,UN,5.12,3.584,AETNA [1000108],AETNA [100010801],,,76.8,,3.93,0.222255,85118.57664,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-11,NDC,outpatient,1,UN,5.12,3.584,AETNA [1000108],AETNA [100010801],,,76.8,,3.93,0.222255,85118.57664,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,00054-8550-25,NDC,outpatient,1,UN,5.49,3.843,AETNA [1000108],AETNA [100010801],,,76.8,,4.22,0.222255,85118.57664,percent of total billed charges,
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-136367,CDM,S5000,HCPCS,250,RC,44567-0601-04,NDC,outpatient,10,ML,205.59,143.913,AETNA [1000108],AETNA [100010801],,,76.8,,157.89,0.222255,85118.57664,percent of total billed charges,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,53329-0172-10,NDC,outpatient,71,GR,15.17,10.619,AETNA [1000108],AETNA [100010801],,,76.8,,11.65,0.222255,85118.57664,percent of total billed charges,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,11701-0067-23,NDC,outpatient,57,GR,25.88,18.116,AETNA [1000108],AETNA [100010801],,,76.8,,19.88,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,99999-0001-85,NDC,outpatient,275,ML,59.61,41.727,AETNA [1000108],AETNA [100010801],,,76.8,,45.78,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70092-9054-05,NDC,outpatient,275,ML,111.55,78.085,AETNA [1000108],AETNA [100010801],,,76.8,,85.67,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,71506-0015-58,NDC,outpatient,275,ML,93.39,65.373,AETNA [1000108],AETNA [100010801],,,76.8,,71.72,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70004-0923-59,NDC,outpatient,275,ML,170.02,119.014,AETNA [1000108],AETNA [100010801],,,76.8,,130.58,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-00,NDC,outpatient,15,ML,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-15,NDC,outpatient,15,ML,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,76154-0818-05,NDC,outpatient,125,ML,82.75,57.925,AETNA [1000108],AETNA [100010801],,,76.8,,63.55,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,99999-0003-40,NDC,outpatient,125,ML,51.6,36.12,AETNA [1000108],AETNA [100010801],,,76.8,,39.63,0.222255,85118.57664,percent of total billed charges,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1068-07,NDC,outpatient,500,ML,106.3,74.41,AETNA [1000108],AETNA [100010801],,,76.8,,81.64,0.222255,85118.57664,percent of total billed charges,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1552-07,NDC,outpatient,500,ML,97.53,68.271,AETNA [1000108],AETNA [100010801],,,76.8,,74.9,0.222255,85118.57664,percent of total billed charges,
LINACLOTIDE 72 MCG ORAL CAPS,RX-138008,CDM,S5000,HCPCS,259,RC,00456-1203-30,NDC,outpatient,1,UN,74.11,51.877,AETNA [1000108],AETNA [100010801],,,76.8,,56.92,0.222255,85118.57664,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,57896-0145-14,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,00536-1263-28,NDC,outpatient,28,GR,4.99,3.493,AETNA [1000108],AETNA [100010801],,,76.8,,3.83,0.222255,85118.57664,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,58980-0011-10,NDC,outpatient,28.35,GR,10.1,7.07,AETNA [1000108],AETNA [100010801],,,76.8,,7.76,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,71506-0019-59,NDC,outpatient,540,ML,128.46,89.922,AETNA [1000108],AETNA [100010801],,,76.8,,98.66,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,99999-0002-01,NDC,outpatient,540,ML,36.84,25.788,AETNA [1000108],AETNA [100010801],,,76.8,,28.29,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,99999-0002-00,NDC,outpatient,535,ML,35.39,24.773,AETNA [1000108],AETNA [100010801],,,76.8,,27.18,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,71506-0017-59,NDC,outpatient,535,ML,119.16,83.412,AETNA [1000108],AETNA [100010801],,,76.8,,91.51,0.222255,85118.57664,percent of total billed charges,
BENZOCAINE 20 % MT AERO,RX-138339,CDM,S5000,HCPCS,259,RC,00283-0679-02,NDC,outpatient,57,GR,120.74,84.518,AETNA [1000108],AETNA [100010801],,,76.8,,92.73,0.222255,85118.57664,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP,RX-138354,CDM,S5000,HCPCS,250,RC,10122-0510-01,NDC,outpatient,1.5,ML,1807.78,1265.446,AETNA [1000108],AETNA [100010801],,,76.8,,1388.38,0.222255,85118.57664,percent of total billed charges,
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,RX-138355,CDM,S5000,HCPCS,250,RC,10122-0510-03,NDC,outpatient,3,ML,2153.49,1507.443,AETNA [1000108],AETNA [100010801],,,76.8,,1653.88,0.222255,85118.57664,percent of total billed charges,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00115-5211-16,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-11,NDC,outpatient,1,UN,12.93,9.051,AETNA [1000108],AETNA [100010801],,,76.8,,9.93,0.222255,85118.57664,percent of total billed charges,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00009-0450-03,NDC,outpatient,1,UN,9.24,6.468,AETNA [1000108],AETNA [100010801],,,76.8,,7.1,0.222255,85118.57664,percent of total billed charges,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,59762-0450-01,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-21,NDC,outpatient,1,UN,12.93,9.051,AETNA [1000108],AETNA [100010801],,,76.8,,9.93,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,99999-0003-24,NDC,outpatient,100,ML,48.85,34.195,AETNA [1000108],AETNA [100010801],,,76.8,,37.52,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1380-36,NDC,outpatient,100,ML,69.27,48.489,AETNA [1000108],AETNA [100010801],,,76.8,,53.2,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1130-36,NDC,outpatient,100,ML,83.73,58.611,AETNA [1000108],AETNA [100010801],,,76.8,,64.3,0.222255,85118.57664,percent of total billed charges,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,00310-6205-30,NDC,outpatient,1,UN,54.15,37.905,AETNA [1000108],AETNA [100010801],,,76.8,,41.59,0.222255,85118.57664,percent of total billed charges,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,66993-0456-30,NDC,outpatient,1,UN,54.61,38.227,AETNA [1000108],AETNA [100010801],,,76.8,,41.94,0.222255,85118.57664,percent of total billed charges,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,66993-0457-30,NDC,outpatient,1,UN,57.77,40.439,AETNA [1000108],AETNA [100010801],,,76.8,,44.37,0.222255,85118.57664,percent of total billed charges,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,00310-6210-39,NDC,outpatient,1,UN,54.15,37.905,AETNA [1000108],AETNA [100010801],,,76.8,,41.59,0.222255,85118.57664,percent of total billed charges,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,00536-5090-08,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,24208-0387-62,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-00,NDC,outpatient,1.14,ML,5813.71,4069.597,AETNA [1000108],AETNA [100010801],,,76.8,,4464.93,0.222255,85118.57664,percent of total billed charges,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-01,NDC,outpatient,1.14,ML,5813.71,4069.597,AETNA [1000108],AETNA [100010801],,,76.8,,4464.93,0.222255,85118.57664,percent of total billed charges,
CARISOPRODOL 350 MG ORAL TABS,RX-1395,CDM,S5000,HCPCS,259,RC,50228-0109-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,00904-7007-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,51672-4130-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,00904-7008-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,51672-4131-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCIUM CARBONATE ANTACID 1250 MG/5ML ORAL SUSP,RX-140541,CDM,S5000,HCPCS,259,RC,00121-4766-05,NDC,outpatient,5,ML,9.19,6.433,AETNA [1000108],AETNA [100010801],,,76.8,,7.06,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-01,NDC,outpatient,1,UN,13.61,9.527,AETNA [1000108],AETNA [100010801],,,76.8,,10.45,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-20,NDC,outpatient,1,UN,13.61,9.527,AETNA [1000108],AETNA [100010801],,,76.8,,10.45,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-01,NDC,outpatient,1,UN,16,11.2,AETNA [1000108],AETNA [100010801],,,76.8,,12.29,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-20,NDC,outpatient,1,UN,16,11.2,AETNA [1000108],AETNA [100010801],,,76.8,,12.29,0.222255,85118.57664,percent of total billed charges,
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,S5000,HCPCS,259,RC,45802-0465-64,NDC,outpatient,120,ML,53.4,37.38,AETNA [1000108],AETNA [100010801],,,76.8,,41.01,0.222255,85118.57664,percent of total billed charges,
BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,RX-141345,CDM,S5000,HCPCS,259,RC,59310-0302-40,NDC,outpatient,10.6,GR,878.5,614.95,AETNA [1000108],AETNA [100010801],,,76.8,,674.69,0.222255,85118.57664,percent of total billed charges,
BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,RX-141346,CDM,S5000,HCPCS,259,RC,59310-0304-80,NDC,outpatient,10.6,GR,1176.28,823.396,AETNA [1000108],AETNA [100010801],,,76.8,,903.38,0.222255,85118.57664,percent of total billed charges,
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG ORAL TABS,RX-142007,CDM,S5000,HCPCS,259,RC,61958-2501-01,NDC,outpatient,1,UN,572.84,400.988,AETNA [1000108],AETNA [100010801],,,76.8,,439.94,0.222255,85118.57664,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,59762-5030-01,NDC,outpatient,35,ML,84.73,59.311,AETNA [1000108],AETNA [100010801],,,76.8,,65.07,0.222255,85118.57664,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,16714-0696-01,NDC,outpatient,35,ML,43.77,30.639,AETNA [1000108],AETNA [100010801],,,76.8,,33.62,0.222255,85118.57664,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,99999-0002-78,NDC,outpatient,5,ML,12.62,8.834,AETNA [1000108],AETNA [100010801],,,76.8,,9.69,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,10006-0700-13,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,57896-0635-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,68585-0005-75,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,71740-0112-30,NDC,outpatient,0.25,ML,14.74,10.318,AETNA [1000108],AETNA [100010801],,,76.8,,11.32,0.222255,85118.57664,percent of total billed charges,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,99999-0003-49,NDC,outpatient,1,ML,58.94,41.258,AETNA [1000108],AETNA [100010801],,,76.8,,45.27,0.222255,85118.57664,percent of total billed charges,
DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG ORAL TABS,RX-143657,CDM,S5000,HCPCS,259,RC,59676-0800-30,NDC,outpatient,1,UN,678.69,475.083,AETNA [1000108],AETNA [100010801],,,76.8,,521.23,0.222255,85118.57664,percent of total billed charges,
PIMAVANSERIN TARTRATE 34 MG ORAL CAPS,RX-143683,CDM,S5000,HCPCS,259,RC,63090-0340-30,NDC,outpatient,1,UN,740.93,518.651,AETNA [1000108],AETNA [100010801],,,76.8,,569.03,0.222255,85118.57664,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-01,NDC,outpatient,1,UN,69.73,48.811,AETNA [1000108],AETNA [100010801],,,76.8,,53.55,0.222255,85118.57664,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-39,NDC,outpatient,1,UN,69.73,48.811,AETNA [1000108],AETNA [100010801],,,76.8,,53.55,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-16,NDC,outpatient,1,UN,58.96,41.272,AETNA [1000108],AETNA [100010801],,,76.8,,45.28,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,52817-0610-04,NDC,outpatient,1,UN,36.6,25.62,AETNA [1000108],AETNA [100010801],,,76.8,,28.11,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-99,NDC,outpatient,1,UN,58.96,41.272,AETNA [1000108],AETNA [100010801],,,76.8,,45.28,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-54,NDC,outpatient,1,UN,89.34,62.538,AETNA [1000108],AETNA [100010801],,,76.8,,68.61,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-01,NDC,outpatient,1,UN,43.76,30.632,AETNA [1000108],AETNA [100010801],,,76.8,,33.61,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-04,NDC,outpatient,1,UN,89.34,62.538,AETNA [1000108],AETNA [100010801],,,76.8,,68.61,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,82089-0102-34,NDC,outpatient,1,UN,502.38,351.666,AETNA [1000108],AETNA [100010801],,,76.8,,385.83,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-04,NDC,outpatient,1,UN,43.76,30.632,AETNA [1000108],AETNA [100010801],,,76.8,,33.61,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-04,NDC,outpatient,1,UN,122.13,85.491,AETNA [1000108],AETNA [100010801],,,76.8,,93.8,0.222255,85118.57664,percent of total billed charges,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-54,NDC,outpatient,1,UN,122.13,85.491,AETNA [1000108],AETNA [100010801],,,76.8,,93.8,0.222255,85118.57664,percent of total billed charges,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,24208-0485-10,NDC,outpatient,10,ML,36.09,25.263,AETNA [1000108],AETNA [100010801],,,76.8,,27.72,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,42571-0141-26,NDC,outpatient,10,ML,151.26,105.882,AETNA [1000108],AETNA [100010801],,,76.8,,116.17,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,61314-0019-10,NDC,outpatient,10,ML,71.78,50.246,AETNA [1000108],AETNA [100010801],,,76.8,,55.13,0.222255,85118.57664,percent of total billed charges,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-32,NDC,outpatient,3,ML,93.63,65.541,AETNA [1000108],AETNA [100010801],,,76.8,,71.91,0.222255,85118.57664,percent of total billed charges,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-93,NDC,outpatient,3,ML,93.63,65.541,AETNA [1000108],AETNA [100010801],,,76.8,,71.91,0.222255,85118.57664,percent of total billed charges,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-15,NDC,outpatient,1,UN,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-11,NDC,outpatient,1,UN,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-15,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-11,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-02,NDC,outpatient,5,ML,2091.2,1463.84,AETNA [1000108],AETNA [100010801],,,76.8,,1606.04,0.222255,85118.57664,percent of total billed charges,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-15,NDC,outpatient,5,ML,2091.2,1463.84,AETNA [1000108],AETNA [100010801],,,76.8,,1606.04,0.222255,85118.57664,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,99999-0002-40,NDC,outpatient,5,ML,47,32.9,AETNA [1000108],AETNA [100010801],,,76.8,,36.1,0.222255,85118.57664,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,69238-1731-02,NDC,outpatient,473,ML,2201.68,1541.176,AETNA [1000108],AETNA [100010801],,,76.8,,1690.89,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL ER 180 MG ORAL TBCR,RX-14626,CDM,S5000,HCPCS,259,RC,75834-0158-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-11,NDC,outpatient,1,UN,9.29,6.503,AETNA [1000108],AETNA [100010801],,,76.8,,7.13,0.222255,85118.57664,percent of total billed charges,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-21,NDC,outpatient,1,UN,9.29,6.503,AETNA [1000108],AETNA [100010801],,,76.8,,7.13,0.222255,85118.57664,percent of total billed charges,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00904-7179-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00093-0058-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,29300-0355-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ACETIC ACID 5 % SOLN,RX-14702,CDM,S5000,HCPCS,259,RC,99999-0000-92,NDC,outpatient,60,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,00904-7163-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GLYBURIDE MICRONIZED 1.5 MG ORAL TABS,RX-14777,CDM,S5000,HCPCS,259,RC,00093-8034-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147794,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,AETNA [1000108],AETNA [100010801],,,76.8,,75.52,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-03,NDC,outpatient,100,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-01,NDC,outpatient,100,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-30,NDC,outpatient,1,UN,14.17,9.919,AETNA [1000108],AETNA [100010801],,,76.8,,10.88,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-01,NDC,outpatient,1,UN,14.17,9.919,AETNA [1000108],AETNA [100010801],,,76.8,,10.88,0.222255,85118.57664,percent of total billed charges,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-11,NDC,outpatient,1,UN,2.93,2.051,AETNA [1000108],AETNA [100010801],,,76.8,,2.25,0.222255,85118.57664,percent of total billed charges,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-15,NDC,outpatient,1,UN,2.93,2.051,AETNA [1000108],AETNA [100010801],,,76.8,,2.25,0.222255,85118.57664,percent of total billed charges,
TIZANIDINE HCL 4 MG ORAL TABS,RX-14793,CDM,S5000,HCPCS,259,RC,00904-6418-61,NDC,outpatient,1,UN,1.85,1.295,AETNA [1000108],AETNA [100010801],,,76.8,,1.42,0.222255,85118.57664,percent of total billed charges,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,64764-0544-11,NDC,outpatient,1,UN,56.9,39.83,AETNA [1000108],AETNA [100010801],,,76.8,,43.7,0.222255,85118.57664,percent of total billed charges,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-30,NDC,outpatient,1,UN,20.73,14.511,AETNA [1000108],AETNA [100010801],,,76.8,,15.92,0.222255,85118.57664,percent of total billed charges,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-32,NDC,outpatient,1,UN,22.99,16.093,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,0.222255,85118.57664,percent of total billed charges,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-88,NDC,outpatient,1,UN,22.99,16.093,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,0.222255,85118.57664,percent of total billed charges,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-77,NDC,outpatient,1,UN,20.73,14.511,AETNA [1000108],AETNA [100010801],,,76.8,,15.92,0.222255,85118.57664,percent of total billed charges,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-01,NDC,outpatient,1,UN,1.75,1.225,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-11,NDC,outpatient,1,UN,1.75,1.225,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-11,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,00904-7048-61,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-15,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,69097-0579-67,NDC,outpatient,1,UN,204.35,143.045,AETNA [1000108],AETNA [100010801],,,76.8,,156.94,0.222255,85118.57664,percent of total billed charges,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-94,NDC,outpatient,1,UN,214.58,150.206,AETNA [1000108],AETNA [100010801],,,76.8,,164.8,0.222255,85118.57664,percent of total billed charges,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-99,NDC,outpatient,1,UN,214.58,150.206,AETNA [1000108],AETNA [100010801],,,76.8,,164.8,0.222255,85118.57664,percent of total billed charges,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,99999-0004-54,NDC,outpatient,5,ML,14.67,10.269,AETNA [1000108],AETNA [100010801],,,76.8,,11.27,0.222255,85118.57664,percent of total billed charges,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,70748-0299-01,NDC,outpatient,210,ML,615.84,431.088,AETNA [1000108],AETNA [100010801],,,76.8,,472.97,0.222255,85118.57664,percent of total billed charges,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-03,NDC,outpatient,30,ML,8.02,5.614,AETNA [1000108],AETNA [100010801],,,76.8,,6.16,0.222255,85118.57664,percent of total billed charges,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-01,NDC,outpatient,30,ML,8.02,5.614,AETNA [1000108],AETNA [100010801],,,76.8,,6.16,0.222255,85118.57664,percent of total billed charges,
MOEXIPRIL HCL 7.5 MG ORAL TABS,RX-15025,CDM,S5000,HCPCS,259,RC,68462-0209-01,NDC,outpatient,1,UN,3.46,2.422,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,00904-2085-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0101-44,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0140-03,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROCORT-PRAMOXINE (PERIANAL) 2.5-1 % EX CREA,RX-150325,CDM,S5000,HCPCS,259,RC,45802-0472-64,NDC,outpatient,30,GR,583,408.1,AETNA [1000108],AETNA [100010801],,,76.8,,447.74,0.222255,85118.57664,percent of total billed charges,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,99999-0001-49,NDC,outpatient,60,ML,11.75,8.225,AETNA [1000108],AETNA [100010801],,,76.8,,9.02,0.222255,85118.57664,percent of total billed charges,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,51552-0051-06,NDC,outpatient,500,ML,97.9,68.53,AETNA [1000108],AETNA [100010801],,,76.8,,75.19,0.222255,85118.57664,percent of total billed charges,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-59,NDC,outpatient,15,ML,10.55,7.385,AETNA [1000108],AETNA [100010801],,,76.8,,8.1,0.222255,85118.57664,percent of total billed charges,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-62,NDC,outpatient,15,ML,10.55,7.385,AETNA [1000108],AETNA [100010801],,,76.8,,8.1,0.222255,85118.57664,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-01,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-01,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-20,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-11,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,00087-0405-01,NDC,outpatient,0.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,99999-0001-69,NDC,outpatient,0.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TACROLIMUS ER 1 MG ORAL TB24,RX-151676,CDM,S5000,HCPCS,259,RC,68992-3010-03,NDC,outpatient,1,UN,3.04,2.128,AETNA [1000108],AETNA [100010801],,,76.8,,2.33,0.222255,85118.57664,percent of total billed charges,
TACROLIMUS ER 0.75 MG ORAL TB24,RX-151678,CDM,S5000,HCPCS,259,RC,68992-3075-03,NDC,outpatient,1,UN,2.28,1.596,AETNA [1000108],AETNA [100010801],,,76.8,,1.75,0.222255,85118.57664,percent of total billed charges,
TACROLIMUS ER 4 MG ORAL TB24,RX-151679,CDM,S5000,HCPCS,259,RC,68992-3040-03,NDC,outpatient,1,UN,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-59,NDC,outpatient,10,ML,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,99999-0002-42,NDC,outpatient,10,ML,1.6,1.12,AETNA [1000108],AETNA [100010801],,,76.8,,1.23,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-10,NDC,outpatient,10,ML,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-08,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-10,NDC,outpatient,10,ML,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-01,NDC,outpatient,1,ML,93.05,65.135,AETNA [1000108],AETNA [100010801],,,76.8,,71.46,0.222255,85118.57664,percent of total billed charges,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-25,NDC,outpatient,1,ML,93.05,65.135,AETNA [1000108],AETNA [100010801],,,76.8,,71.46,0.222255,85118.57664,percent of total billed charges,
METHACHOLINE CHLORIDE IN KIT,RX-151916,CDM,S5000,HCPCS,259,RC,69374-0542-06,NDC,outpatient,18,ML,600.75,420.525,AETNA [1000108],AETNA [100010801],,,76.8,,461.38,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,00536-1294-97,NDC,outpatient,100,GR,33.38,23.366,AETNA [1000108],AETNA [100010801],,,76.8,,25.64,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,43598-0977-10,NDC,outpatient,100,GR,59.19,41.433,AETNA [1000108],AETNA [100010801],,,76.8,,45.46,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,69097-0524-44,NDC,outpatient,100,GR,59.63,41.741,AETNA [1000108],AETNA [100010801],,,76.8,,45.8,0.222255,85118.57664,percent of total billed charges,
SUMATRIPTAN SUCCINATE 25 MG ORAL TABS,RX-15327,CDM,S5000,HCPCS,259,RC,65862-0146-36,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,16571-0202-10,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,61442-0102-01,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,00228-2550-11,NDC,outpatient,1,UN,1.63,1.141,AETNA [1000108],AETNA [100010801],,,76.8,,1.25,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-01,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-11,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 75 MG ORAL TBEC,RX-15341,CDM,S5000,HCPCS,259,RC,16571-0201-06,NDC,outpatient,1,UN,1.46,1.022,AETNA [1000108],AETNA [100010801],,,76.8,,1.12,0.222255,85118.57664,percent of total billed charges,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,00225-0525-47,NDC,outpatient,14.1,GR,10.92,7.644,AETNA [1000108],AETNA [100010801],,,76.8,,8.39,0.222255,85118.57664,percent of total billed charges,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,05928-0000-99,NDC,outpatient,28.4,GR,22.75,15.925,AETNA [1000108],AETNA [100010801],,,76.8,,17.47,0.222255,85118.57664,percent of total billed charges,
RIMANTADINE HCL 100 MG ORAL TABS,RX-15440,CDM,S5000,HCPCS,259,RC,00115-1911-01,NDC,outpatient,1,UN,10.21,7.147,AETNA [1000108],AETNA [100010801],,,76.8,,7.84,0.222255,85118.57664,percent of total billed charges,
CHERRY ORAL SYRP,RX-1562,CDM,S5000,HCPCS,259,RC,00395-2662-16,NDC,outpatient,473,ML,78.58,55.006,AETNA [1000108],AETNA [100010801],,,76.8,,60.35,0.222255,85118.57664,percent of total billed charges,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-13,NDC,outpatient,500,ML,73.85,51.695,AETNA [1000108],AETNA [100010801],,,76.8,,56.72,0.222255,85118.57664,percent of total billed charges,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-09,NDC,outpatient,250,ML,59.39,41.573,AETNA [1000108],AETNA [100010801],,,76.8,,45.61,0.222255,85118.57664,percent of total billed charges,
AMANTADINE HCL 50 MG/5ML ORAL SOLN,RX-156382,CDM,S5000,HCPCS,259,RC,00121-0646-10,NDC,outpatient,10,ML,13.67,9.569,AETNA [1000108],AETNA [100010801],,,76.8,,10.5,0.222255,85118.57664,percent of total billed charges,
ALENDRONATE SODIUM 10 MG ORAL TABS,RX-15661,CDM,S5000,HCPCS,259,RC,16714-0631-01,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156724,CDM,S5000,HCPCS,250,RC,60267-0705-50,NDC,outpatient,50,ML,431.65,302.155,AETNA [1000108],AETNA [100010801],,,76.8,,331.51,0.222255,85118.57664,percent of total billed charges,
PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN,RX-156740,CDM,S5000,HCPCS,250,RC,24571-0108-06,NDC,outpatient,5000,ML,294.88,206.416,AETNA [1000108],AETNA [100010801],,,76.8,,226.47,0.222255,85118.57664,percent of total billed charges,
PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN,RX-156741,CDM,S5000,HCPCS,250,RC,24571-0105-06,NDC,outpatient,5000,ML,294.88,206.416,AETNA [1000108],AETNA [100010801],,,76.8,,226.47,0.222255,85118.57664,percent of total billed charges,
PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN,RX-156742,CDM,S5000,HCPCS,250,RC,24571-0102-06,NDC,outpatient,5000,ML,294.88,206.416,AETNA [1000108],AETNA [100010801],,,76.8,,226.47,0.222255,85118.57664,percent of total billed charges,
PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L EC SOLN,RX-156743,CDM,S5000,HCPCS,250,RC,24571-0103-06,NDC,outpatient,5000,ML,325.06,227.542,AETNA [1000108],AETNA [100010801],,,76.8,,249.65,0.222255,85118.57664,percent of total billed charges,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,00093-1060-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,60505-0159-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,60505-0823-06,NDC,outpatient,3.7,ML,230.15,161.105,AETNA [1000108],AETNA [100010801],,,76.8,,176.76,0.222255,85118.57664,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,49884-0161-11,NDC,outpatient,3.7,ML,207.33,145.131,AETNA [1000108],AETNA [100010801],,,76.8,,159.23,0.222255,85118.57664,percent of total billed charges,
CARVEDILOL 6.25 MG ORAL TABS,RX-15747,CDM,S5000,HCPCS,259,RC,00904-6301-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,00904-6302-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,68382-0094-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,59762-3120-01,NDC,outpatient,18.75,ML,76.85,53.795,AETNA [1000108],AETNA [100010801],,,76.8,,59.02,0.222255,85118.57664,percent of total billed charges,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,99999-0002-81,NDC,outpatient,6.25,ML,21.03,14.721,AETNA [1000108],AETNA [100010801],,,76.8,,16.15,0.222255,85118.57664,percent of total billed charges,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,00093-2026-23,NDC,outpatient,18.75,ML,62.17,43.519,AETNA [1000108],AETNA [100010801],,,76.8,,47.75,0.222255,85118.57664,percent of total billed charges,
DARUNAVIR 800 MG ORAL TABS,RX-158170,CDM,S5000,HCPCS,259,RC,59676-0566-30,NDC,outpatient,1,UN,310.53,217.371,AETNA [1000108],AETNA [100010801],,,76.8,,238.49,0.222255,85118.57664,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5924-10,NDC,outpatient,10,ML,322.63,225.841,AETNA [1000108],AETNA [100010801],,,76.8,,247.78,0.222255,85118.57664,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5926-05,NDC,outpatient,3,ML,50.03,35.021,AETNA [1000108],AETNA [100010801],,,76.8,,38.42,0.222255,85118.57664,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00002-7533-01,NDC,outpatient,3,ML,80.06,56.042,AETNA [1000108],AETNA [100010801],,,76.8,,61.49,0.222255,85118.57664,percent of total billed charges,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,00904-6583-04,NDC,outpatient,1,UN,21.27,14.889,AETNA [1000108],AETNA [100010801],,,76.8,,16.34,0.222255,85118.57664,percent of total billed charges,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,64380-0710-03,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLN,RX-15881,CDM,S5000,HCPCS,259,RC,54838-0566-70,NDC,outpatient,15,ML,23.1,16.17,AETNA [1000108],AETNA [100010801],,,76.8,,17.74,0.222255,85118.57664,percent of total billed charges,
ACARBOSE 50 MG ORAL TABS,RX-15895,CDM,S5000,HCPCS,259,RC,64380-0759-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,S5000,HCPCS,259,RC,00436-0936-16,NDC,outpatient,473,ML,52.63,36.841,AETNA [1000108],AETNA [100010801],,,76.8,,40.42,0.222255,85118.57664,percent of total billed charges,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-02,NDC,outpatient,1,UN,571.55,400.085,AETNA [1000108],AETNA [100010801],,,76.8,,438.95,0.222255,85118.57664,percent of total billed charges,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-20,NDC,outpatient,1,UN,3544.84,2481.388,AETNA [1000108],AETNA [100010801],,,76.8,,2722.44,0.222255,85118.57664,percent of total billed charges,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-30,NDC,outpatient,1,UN,3544.84,2481.388,AETNA [1000108],AETNA [100010801],,,76.8,,2722.44,0.222255,85118.57664,percent of total billed charges,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-03,NDC,outpatient,1,UN,571.55,400.085,AETNA [1000108],AETNA [100010801],,,76.8,,438.95,0.222255,85118.57664,percent of total billed charges,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,00406-0527-10,NDC,outpatient,0.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,99999-0002-10,NDC,outpatient,10,ML,27.28,19.096,AETNA [1000108],AETNA [100010801],,,76.8,,20.95,0.222255,85118.57664,percent of total billed charges,
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-160113,CDM,S5000,HCPCS,259,RC,00046-0872-21,NDC,outpatient,30,GR,1850.58,1295.406,AETNA [1000108],AETNA [100010801],,,76.8,,1421.25,0.222255,85118.57664,percent of total billed charges,
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,S5000,HCPCS,259,RC,16714-0763-01,NDC,outpatient,60,GR,327.35,229.145,AETNA [1000108],AETNA [100010801],,,76.8,,251.4,0.222255,85118.57664,percent of total billed charges,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-51,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,80681-0100-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-11,NDC,outpatient,1,UN,3.58,2.506,AETNA [1000108],AETNA [100010801],,,76.8,,2.75,0.222255,85118.57664,percent of total billed charges,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-21,NDC,outpatient,1,UN,7.9,5.53,AETNA [1000108],AETNA [100010801],,,76.8,,6.07,0.222255,85118.57664,percent of total billed charges,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,23155-0490-01,NDC,outpatient,1,UN,1.27,0.889,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-11,NDC,outpatient,1,UN,7.9,5.53,AETNA [1000108],AETNA [100010801],,,76.8,,6.07,0.222255,85118.57664,percent of total billed charges,
METHYLENE BLUE 1 % IV SOLN,RX-160649,CDM,S5000,HCPCS,250,RC,54288-0147-01,NDC,outpatient,10,ML,616.77,431.739,AETNA [1000108],AETNA [100010801],,,76.8,,473.68,0.222255,85118.57664,percent of total billed charges,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,66689-0203-04,NDC,outpatient,120,ML,73.16,51.212,AETNA [1000108],AETNA [100010801],,,76.8,,56.19,0.222255,85118.57664,percent of total billed charges,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,00574-0520-74,NDC,outpatient,120,ML,51.8,36.26,AETNA [1000108],AETNA [100010801],,,76.8,,39.78,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,00054-0045-44,NDC,outpatient,30,ML,160.2,112.14,AETNA [1000108],AETNA [100010801],,,76.8,,123.03,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,24208-0398-30,NDC,outpatient,30,ML,45.66,31.962,AETNA [1000108],AETNA [100010801],,,76.8,,35.07,0.222255,85118.57664,percent of total billed charges,
CALCIUM CARB-CHOLECALCIFEROL 600-5 MG-MCG ORAL TABS,RX-160700,CDM,S5000,HCPCS,259,RC,80681-0138-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,00054-0046-41,NDC,outpatient,15,ML,147.99,103.593,AETNA [1000108],AETNA [100010801],,,76.8,,113.66,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,60505-0827-01,NDC,outpatient,15,ML,69.49,48.643,AETNA [1000108],AETNA [100010801],,,76.8,,53.37,0.222255,85118.57664,percent of total billed charges,
FAMCICLOVIR 250 MG ORAL TABS,RX-16081,CDM,S5000,HCPCS,259,RC,60505-3246-03,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-03,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,00536-3223-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RILUZOLE 50 MG ORAL TABS,RX-16124,CDM,S5000,HCPCS,259,RC,67877-0286-60,NDC,outpatient,1,UN,2.96,2.072,AETNA [1000108],AETNA [100010801],,,76.8,,2.27,0.222255,85118.57664,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,00054-3120-41,NDC,outpatient,1,ML,24.45,17.115,AETNA [1000108],AETNA [100010801],,,76.8,,18.78,0.222255,85118.57664,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,99999-0002-71,NDC,outpatient,1,ML,19.3,13.51,AETNA [1000108],AETNA [100010801],,,76.8,,14.82,0.222255,85118.57664,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,63304-0241-59,NDC,outpatient,1,ML,19.3,13.51,AETNA [1000108],AETNA [100010801],,,76.8,,14.82,0.222255,85118.57664,percent of total billed charges,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,00555-0159-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-20,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-01,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-20,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-01,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,
EUCERIN ORIGINAL HEALING EX CREA,RX-162713,CDM,S5000,HCPCS,259,RC,72140-0038-68,NDC,outpatient,57,GR,20.04,14.028,AETNA [1000108],AETNA [100010801],,,76.8,,15.39,0.222255,85118.57664,percent of total billed charges,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,55111-0321-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-11,NDC,outpatient,1,UN,2.06,1.442,AETNA [1000108],AETNA [100010801],,,76.8,,1.58,0.222255,85118.57664,percent of total billed charges,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-01,NDC,outpatient,1,UN,2.06,1.442,AETNA [1000108],AETNA [100010801],,,76.8,,1.58,0.222255,85118.57664,percent of total billed charges,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PHENYLEPH-SHARK LIV OIL-MO-PET 0.25-3-14-71.9 % RE OINT,RX-16462,CDM,S5000,HCPCS,259,RC,00573-2871-93,NDC,outpatient,28,GR,25.8,18.06,AETNA [1000108],AETNA [100010801],,,76.8,,19.81,0.222255,85118.57664,percent of total billed charges,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-11,NDC,outpatient,1,UN,4.66,3.262,AETNA [1000108],AETNA [100010801],,,76.8,,3.58,0.222255,85118.57664,percent of total billed charges,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,00904-7129-61,NDC,outpatient,1,UN,10.41,7.287,AETNA [1000108],AETNA [100010801],,,76.8,,7.99,0.222255,85118.57664,percent of total billed charges,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-15,NDC,outpatient,1,UN,4.66,3.262,AETNA [1000108],AETNA [100010801],,,76.8,,3.58,0.222255,85118.57664,percent of total billed charges,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,00904-7132-61,NDC,outpatient,1,UN,20.86,14.602,AETNA [1000108],AETNA [100010801],,,76.8,,16.02,0.222255,85118.57664,percent of total billed charges,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,69238-1060-01,NDC,outpatient,1,UN,6.98,4.886,AETNA [1000108],AETNA [100010801],,,76.8,,5.36,0.222255,85118.57664,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-15,NDC,outpatient,1,UN,7.19,5.033,AETNA [1000108],AETNA [100010801],,,76.8,,5.52,0.222255,85118.57664,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-11,NDC,outpatient,1,UN,7.19,5.033,AETNA [1000108],AETNA [100010801],,,76.8,,5.52,0.222255,85118.57664,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,69238-1056-01,NDC,outpatient,1,UN,2.88,2.016,AETNA [1000108],AETNA [100010801],,,76.8,,2.21,0.222255,85118.57664,percent of total billed charges,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00065-4011-05,NDC,outpatient,5,ML,42.77,29.939,AETNA [1000108],AETNA [100010801],,,76.8,,32.85,0.222255,85118.57664,percent of total billed charges,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00536-1252-40,NDC,outpatient,5,ML,30.09,21.063,AETNA [1000108],AETNA [100010801],,,76.8,,23.11,0.222255,85118.57664,percent of total billed charges,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,72485-0617-10,NDC,outpatient,5,ML,28.93,20.251,AETNA [1000108],AETNA [100010801],,,76.8,,22.22,0.222255,85118.57664,percent of total billed charges,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-20,NDC,outpatient,1,UN,7.86,5.502,AETNA [1000108],AETNA [100010801],,,76.8,,6.04,0.222255,85118.57664,percent of total billed charges,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-01,NDC,outpatient,1,UN,7.86,5.502,AETNA [1000108],AETNA [100010801],,,76.8,,6.04,0.222255,85118.57664,percent of total billed charges,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-01,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-11,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,63739-0888-10,NDC,outpatient,1,UN,2.7,1.89,AETNA [1000108],AETNA [100010801],,,76.8,,2.07,0.222255,85118.57664,percent of total billed charges,
FERROUS SULFATE ER 45 MG ORAL TBCR,RX-167735,CDM,S5000,HCPCS,259,RC,10006-0730-13,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,S5000,HCPCS,250,RC,00942-0641-04,NDC,outpatient,1000,ML,60.15,42.105,AETNA [1000108],AETNA [100010801],,,76.8,,46.2,0.222255,85118.57664,percent of total billed charges,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,20555-0036-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYOSCYAMINE SULFATE ER 0.375 MG ORAL TB12,RX-17010,CDM,S5000,HCPCS,259,RC,51525-0115-01,NDC,outpatient,1,UN,1.16,0.812,AETNA [1000108],AETNA [100010801],,,76.8,,0.89,0.222255,85118.57664,percent of total billed charges,
TRANDOLAPRIL 1 MG ORAL TABS,RX-17017,CDM,S5000,HCPCS,259,RC,68180-0566-01,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,
SELEGILINE HCL 5 MG ORAL CAPS,RX-17280,CDM,S5000,HCPCS,259,RC,60505-0055-01,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0031-47,NDC,outpatient,396,GR,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,0.222255,85118.57664,percent of total billed charges,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0452-31,NDC,outpatient,50,GR,20.25,14.175,AETNA [1000108],AETNA [100010801],,,76.8,,15.55,0.222255,85118.57664,percent of total billed charges,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,61924-0184-04,NDC,outpatient,106,GR,13.68,9.576,AETNA [1000108],AETNA [100010801],,,76.8,,10.51,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,27808-0002-01,NDC,outpatient,0.25,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,65162-0673-84,NDC,outpatient,0.25,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,99999-0003-81,NDC,outpatient,1,ML,4.12,2.884,AETNA [1000108],AETNA [100010801],,,76.8,,3.16,0.222255,85118.57664,percent of total billed charges,
AZITHROMYCIN 600 MG ORAL TABS,RX-17387,CDM,S5000,HCPCS,259,RC,62332-0253-30,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN HCL 150 MG ORAL CAPS,RX-1740,CDM,S5000,HCPCS,259,RC,00904-5959-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NEVIRAPINE 200 MG ORAL TABS,RX-17403,CDM,S5000,HCPCS,259,RC,31722-0505-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,00168-0201-60,NDC,outpatient,60,ML,139.11,97.377,AETNA [1000108],AETNA [100010801],,,76.8,,106.84,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,45802-0562-02,NDC,outpatient,60,ML,48.6,34.02,AETNA [1000108],AETNA [100010801],,,76.8,,37.32,0.222255,85118.57664,percent of total billed charges,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,00904-6519-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,RX-17524,CDM,S5000,HCPCS,250,RC,59584-0138-01,NDC,outpatient,0.1,ML,121.71,85.197,AETNA [1000108],AETNA [100010801],,,76.8,,93.47,0.222255,85118.57664,percent of total billed charges,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-11,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-01,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABS,RX-1759,CDM,S5000,HCPCS,259,RC,13107-0319-01,NDC,outpatient,1,UN,4.43,3.101,AETNA [1000108],AETNA [100010801],,,76.8,,3.4,0.222255,85118.57664,percent of total billed charges,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,51672-2002-02,NDC,outpatient,30,GR,6.01,4.207,AETNA [1000108],AETNA [100010801],,,76.8,,4.62,0.222255,85118.57664,percent of total billed charges,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,45802-0434-11,NDC,outpatient,30,GR,10.42,7.294,AETNA [1000108],AETNA [100010801],,,76.8,,8,0.222255,85118.57664,percent of total billed charges,
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,S5000,HCPCS,259,RC,51672-1260-03,NDC,outpatient,30,ML,97.86,68.502,AETNA [1000108],AETNA [100010801],,,76.8,,75.16,0.222255,85118.57664,percent of total billed charges,
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,S5000,HCPCS,259,RC,51672-2003-06,NDC,outpatient,45,GR,11.82,8.274,AETNA [1000108],AETNA [100010801],,,76.8,,9.08,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,AETNA [1000108],AETNA [100010801],,,76.8,,71.03,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,AETNA [1000108],AETNA [100010801],,,76.8,,90.49,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,AETNA [1000108],AETNA [100010801],,,76.8,,112.64,0.222255,85118.57664,percent of total billed charges,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,24208-0411-05,NDC,outpatient,5,ML,61.95,43.365,AETNA [1000108],AETNA [100010801],,,76.8,,47.58,0.222255,85118.57664,percent of total billed charges,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,71921-0185-05,NDC,outpatient,5,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,0.222255,85118.57664,percent of total billed charges,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,61314-0143-05,NDC,outpatient,5,ML,13.04,9.128,AETNA [1000108],AETNA [100010801],,,76.8,,10.01,0.222255,85118.57664,percent of total billed charges,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,70069-0231-01,NDC,outpatient,5,ML,7.26,5.082,AETNA [1000108],AETNA [100010801],,,76.8,,5.58,0.222255,85118.57664,percent of total billed charges,
B COMPLEX ORAL CAPS,RX-17882,CDM,S5000,HCPCS,259,RC,54629-0560-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 5 MG ORAL TABS,RX-17936,CDM,S5000,HCPCS,259,RC,00904-6377-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DEXAMETHASONE 1 MG/ML ORAL CONC,RX-17946,CDM,S5000,HCPCS,259,RC,00054-3176-44,NDC,outpatient,30,ML,90.92,63.644,AETNA [1000108],AETNA [100010801],,,76.8,,69.83,0.222255,85118.57664,percent of total billed charges,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-21,NDC,outpatient,1,UN,10.83,7.581,AETNA [1000108],AETNA [100010801],,,76.8,,8.32,0.222255,85118.57664,percent of total billed charges,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-11,NDC,outpatient,1,UN,10.83,7.581,AETNA [1000108],AETNA [100010801],,,76.8,,8.32,0.222255,85118.57664,percent of total billed charges,
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,S5000,HCPCS,259,RC,45802-0513-77,NDC,outpatient,140,GR,35.52,24.864,AETNA [1000108],AETNA [100010801],,,76.8,,27.28,0.222255,85118.57664,percent of total billed charges,
CODEINE SULFATE 15 MG ORAL TABS,RX-1801,CDM,S5000,HCPCS,259,RC,00054-0243-24,NDC,outpatient,1,UN,2.94,2.058,AETNA [1000108],AETNA [100010801],,,76.8,,2.26,0.222255,85118.57664,percent of total billed charges,
SENNA 8.6 MG ORAL TABS,RX-18138,CDM,S5000,HCPCS,259,RC,00904-7252-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-03,NDC,outpatient,1,UN,13.56,9.492,AETNA [1000108],AETNA [100010801],,,76.8,,10.41,0.222255,85118.57664,percent of total billed charges,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-01,NDC,outpatient,1,UN,13.56,9.492,AETNA [1000108],AETNA [100010801],,,76.8,,10.41,0.222255,85118.57664,percent of total billed charges,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,65162-0710-09,NDC,outpatient,1,UN,2.83,1.981,AETNA [1000108],AETNA [100010801],,,76.8,,2.17,0.222255,85118.57664,percent of total billed charges,
BISOPROLOL FUMARATE 5 MG ORAL TABS,RX-18288,CDM,S5000,HCPCS,259,RC,29300-0126-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,10135-0742-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,29300-0189-01,NDC,outpatient,1,UN,2.16,1.512,AETNA [1000108],AETNA [100010801],,,76.8,,1.66,0.222255,85118.57664,percent of total billed charges,
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG ORAL TABS,RX-18290,CDM,S5000,HCPCS,259,RC,29300-0188-01,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,68462-0878-30,NDC,outpatient,1,UN,1.61,1.127,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,29300-0187-01,NDC,outpatient,1,UN,2.03,1.421,AETNA [1000108],AETNA [100010801],,,76.8,,1.56,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-15,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-11,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-11,NDC,outpatient,1,UN,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-29,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-15,NDC,outpatient,1,UN,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-11,NDC,outpatient,1,UN,1.28,0.896,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-25,NDC,outpatient,1,UN,1.1,0.77,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-01,NDC,outpatient,1,UN,1.28,0.896,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-15,NDC,outpatient,1,UN,1.64,1.148,AETNA [1000108],AETNA [100010801],,,76.8,,1.26,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,31722-0532-01,NDC,outpatient,1,UN,2.32,1.624,AETNA [1000108],AETNA [100010801],,,76.8,,1.78,0.222255,85118.57664,percent of total billed charges,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-11,NDC,outpatient,1,UN,1.64,1.148,AETNA [1000108],AETNA [100010801],,,76.8,,1.26,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,63739-0904-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,00904-6667-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,00904-6666-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,45963-0556-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,16714-0662-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,63739-0903-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,00904-6665-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,63739-0902-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 2 MG ORAL TABS,RX-18311,CDM,S5000,HCPCS,259,RC,00904-7363-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,00904-7362-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,42291-0910-60,NDC,outpatient,1,UN,11.7,8.19,AETNA [1000108],AETNA [100010801],,,76.8,,8.99,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-11,NDC,outpatient,1,UN,2.72,1.904,AETNA [1000108],AETNA [100010801],,,76.8,,2.09,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-01,NDC,outpatient,1,UN,2.72,1.904,AETNA [1000108],AETNA [100010801],,,76.8,,2.09,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-95,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-25,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-01,NDC,outpatient,1,UN,164.07,114.849,AETNA [1000108],AETNA [100010801],,,76.8,,126.01,0.222255,85118.57664,percent of total billed charges,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-01,NDC,outpatient,1,UN,164.48,115.136,AETNA [1000108],AETNA [100010801],,,76.8,,126.32,0.222255,85118.57664,percent of total billed charges,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-10,NDC,outpatient,1,UN,164.07,114.849,AETNA [1000108],AETNA [100010801],,,76.8,,126.01,0.222255,85118.57664,percent of total billed charges,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-03,NDC,outpatient,1,UN,164.48,115.136,AETNA [1000108],AETNA [100010801],,,76.8,,126.32,0.222255,85118.57664,percent of total billed charges,
CARVEDILOL 3.125 MG ORAL TABS,RX-18551,CDM,S5000,HCPCS,259,RC,00904-6300-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,24208-0463-25,NDC,outpatient,2.5,ML,46.77,32.739,AETNA [1000108],AETNA [100010801],,,76.8,,35.92,0.222255,85118.57664,percent of total billed charges,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,70069-0421-01,NDC,outpatient,2.5,ML,19.9,13.93,AETNA [1000108],AETNA [100010801],,,76.8,,15.28,0.222255,85118.57664,percent of total billed charges,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,59762-0333-02,NDC,outpatient,2.5,ML,18.92,13.244,AETNA [1000108],AETNA [100010801],,,76.8,,14.53,0.222255,85118.57664,percent of total billed charges,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,61314-0547-01,NDC,outpatient,2.5,ML,19.1,13.37,AETNA [1000108],AETNA [100010801],,,76.8,,14.67,0.222255,85118.57664,percent of total billed charges,
DONEPEZIL HCL 5 MG ORAL TABS,RX-18786,CDM,S5000,HCPCS,259,RC,00904-6477-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,43598-0587-23,NDC,outpatient,2,ML,87.58,61.306,AETNA [1000108],AETNA [100010801],,,76.8,,67.26,0.222255,85118.57664,percent of total billed charges,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,67457-0839-02,NDC,outpatient,2,ML,53.45,37.415,AETNA [1000108],AETNA [100010801],,,76.8,,41.05,0.222255,85118.57664,percent of total billed charges,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,72485-0105-01,NDC,outpatient,2,ML,69.91,48.937,AETNA [1000108],AETNA [100010801],,,76.8,,53.69,0.222255,85118.57664,percent of total billed charges,
LEVOFLOXACIN 250 MG ORAL TABS,RX-18918,CDM,S5000,HCPCS,259,RC,00904-6351-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LEVOFLOXACIN 500 MG ORAL TABS,RX-18919,CDM,S5000,HCPCS,259,RC,00904-6352-61,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-11,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-01,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-01,NDC,outpatient,1,UN,2.19,1.533,AETNA [1000108],AETNA [100010801],,,76.8,,1.68,0.222255,85118.57664,percent of total billed charges,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-11,NDC,outpatient,1,UN,2.19,1.533,AETNA [1000108],AETNA [100010801],,,76.8,,1.68,0.222255,85118.57664,percent of total billed charges,
ATORVASTATIN CALCIUM 10 MG ORAL TABS,RX-19176,CDM,S5000,HCPCS,259,RC,00904-6290-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ATORVASTATIN CALCIUM 20 MG ORAL TABS,RX-19178,CDM,S5000,HCPCS,259,RC,00904-6291-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,S5000,HCPCS,259,RC,60505-0833-05,NDC,outpatient,30,ML,24.97,17.479,AETNA [1000108],AETNA [100010801],,,76.8,,19.18,0.222255,85118.57664,percent of total billed charges,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,23155-0823-73,NDC,outpatient,1,UN,8.36,5.852,AETNA [1000108],AETNA [100010801],,,76.8,,6.42,0.222255,85118.57664,percent of total billed charges,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,50742-0118-08,NDC,outpatient,1,UN,13.91,9.737,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,0.222255,85118.57664,percent of total billed charges,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,59762-1005-01,NDC,outpatient,1,UN,22.17,15.519,AETNA [1000108],AETNA [100010801],,,76.8,,17.03,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,S5000,HCPCS,259,RC,70756-0614-30,NDC,outpatient,5,ML,178,124.6,AETNA [1000108],AETNA [100010801],,,76.8,,136.7,0.222255,85118.57664,percent of total billed charges,
BENZOCAINE 20 % MT GEL,RX-19691,CDM,S5000,HCPCS,259,RC,10310-0566-20,NDC,outpatient,11.9,GR,20.34,14.238,AETNA [1000108],AETNA [100010801],,,76.8,,15.62,0.222255,85118.57664,percent of total billed charges,
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,S5000,HCPCS,259,RC,00065-0023-15,NDC,outpatient,1.5,ML,66,46.2,AETNA [1000108],AETNA [100010801],,,76.8,,50.69,0.222255,85118.57664,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,99999-0003-50,NDC,outpatient,1,ML,37.77,26.439,AETNA [1000108],AETNA [100010801],,,76.8,,29.01,0.222255,85118.57664,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,00254-1010-19,NDC,outpatient,30,ML,1132.89,793.023,AETNA [1000108],AETNA [100010801],,,76.8,,870.06,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,24208-0457-05,NDC,outpatient,5,ML,46.46,32.522,AETNA [1000108],AETNA [100010801],,,76.8,,35.68,0.222255,85118.57664,percent of total billed charges,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,61314-0014-25,NDC,outpatient,2.5,ML,39.79,27.853,AETNA [1000108],AETNA [100010801],,,76.8,,30.56,0.222255,85118.57664,percent of total billed charges,
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,S5000,HCPCS,259,RC,11980-0228-05,NDC,outpatient,5,ML,692.51,484.757,AETNA [1000108],AETNA [100010801],,,76.8,,531.85,0.222255,85118.57664,percent of total billed charges,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00548-5400-00,NDC,outpatient,1,ML,75.65,52.955,AETNA [1000108],AETNA [100010801],,,76.8,,58.1,0.222255,85118.57664,percent of total billed charges,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00009-0746-30,NDC,outpatient,1,ML,216.41,151.487,AETNA [1000108],AETNA [100010801],,,76.8,,166.2,0.222255,85118.57664,percent of total billed charges,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,00135-0199-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,49348-0541-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,60505-0560-00,NDC,outpatient,5,ML,32.22,22.554,AETNA [1000108],AETNA [100010801],,,76.8,,24.74,0.222255,85118.57664,percent of total billed charges,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,64980-0515-05,NDC,outpatient,5,ML,58.61,41.027,AETNA [1000108],AETNA [100010801],,,76.8,,45.01,0.222255,85118.57664,percent of total billed charges,
POVIDONE-IODINE 5 % OP SOLN,RX-19791,CDM,S5000,HCPCS,259,RC,00065-0411-30,NDC,outpatient,30,ML,45.26,31.682,AETNA [1000108],AETNA [100010801],,,76.8,,34.76,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-POLYMYXIN-PRAMOXINE 1 % EX CREA,RX-19880,CDM,S5000,HCPCS,259,RC,12547-0407-40,NDC,outpatient,14.2,GR,19.03,13.321,AETNA [1000108],AETNA [100010801],,,76.8,,14.62,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-11,NDC,outpatient,1,UN,1.26,0.882,AETNA [1000108],AETNA [100010801],,,76.8,,0.97,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-01,NDC,outpatient,1,UN,1.26,0.882,AETNA [1000108],AETNA [100010801],,,76.8,,0.97,0.222255,85118.57664,percent of total billed charges,
NELFINAVIR MESYLATE 250 MG ORAL TABS,RX-20032,CDM,S5000,HCPCS,259,RC,63010-0010-30,NDC,outpatient,1,UN,17.47,12.229,AETNA [1000108],AETNA [100010801],,,76.8,,13.42,0.222255,85118.57664,percent of total billed charges,
MESNA 400 MG ORAL TABS,RX-20077,CDM,S5000,HCPCS,259,RC,67108-3565-09,NDC,outpatient,1,UN,287.17,201.019,AETNA [1000108],AETNA [100010801],,,76.8,,220.55,0.222255,85118.57664,percent of total billed charges,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-06,NDC,outpatient,15,ML,121.82,85.274,AETNA [1000108],AETNA [100010801],,,76.8,,93.56,0.222255,85118.57664,percent of total billed charges,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-01,NDC,outpatient,2,ML,47.31,33.117,AETNA [1000108],AETNA [100010801],,,76.8,,36.33,0.222255,85118.57664,percent of total billed charges,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-15,NDC,outpatient,1,UN,2.94,2.058,AETNA [1000108],AETNA [100010801],,,76.8,,2.26,0.222255,85118.57664,percent of total billed charges,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-11,NDC,outpatient,1,UN,2.94,2.058,AETNA [1000108],AETNA [100010801],,,76.8,,2.26,0.222255,85118.57664,percent of total billed charges,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-01,NDC,outpatient,10,ML,375.94,263.158,AETNA [1000108],AETNA [100010801],,,76.8,,288.72,0.222255,85118.57664,percent of total billed charges,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-03,NDC,outpatient,10,ML,375.94,263.158,AETNA [1000108],AETNA [100010801],,,76.8,,288.72,0.222255,85118.57664,percent of total billed charges,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,00172-5241-60,NDC,outpatient,1,UN,3.43,2.401,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,13668-0453-01,NDC,outpatient,1,UN,2.97,2.079,AETNA [1000108],AETNA [100010801],,,76.8,,2.28,0.222255,85118.57664,percent of total billed charges,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-01,NDC,outpatient,20,ML,27.51,19.257,AETNA [1000108],AETNA [100010801],,,76.8,,21.13,0.222255,85118.57664,percent of total billed charges,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-01,NDC,outpatient,10,ML,25.46,17.822,AETNA [1000108],AETNA [100010801],,,76.8,,19.55,0.222255,85118.57664,percent of total billed charges,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-10,NDC,outpatient,10,ML,25.46,17.822,AETNA [1000108],AETNA [100010801],,,76.8,,19.55,0.222255,85118.57664,percent of total billed charges,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-10,NDC,outpatient,20,ML,27.51,19.257,AETNA [1000108],AETNA [100010801],,,76.8,,21.13,0.222255,85118.57664,percent of total billed charges,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,55150-0221-10,NDC,outpatient,10,ML,12.44,8.708,AETNA [1000108],AETNA [100010801],,,76.8,,9.55,0.222255,85118.57664,percent of total billed charges,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-01,NDC,outpatient,10,ML,13.73,9.611,AETNA [1000108],AETNA [100010801],,,76.8,,10.54,0.222255,85118.57664,percent of total billed charges,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-10,NDC,outpatient,10,ML,13.73,9.611,AETNA [1000108],AETNA [100010801],,,76.8,,10.54,0.222255,85118.57664,percent of total billed charges,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX LIQD,RX-20781,CDM,S5000,HCPCS,259,RC,49348-0443-34,NDC,outpatient,118,ML,21.53,15.071,AETNA [1000108],AETNA [100010801],,,76.8,,16.54,0.222255,85118.57664,percent of total billed charges,
MIGLITOL 25 MG ORAL TABS,RX-20799,CDM,S5000,HCPCS,259,RC,69367-0303-01,NDC,outpatient,1,UN,7.35,5.145,AETNA [1000108],AETNA [100010801],,,76.8,,5.64,0.222255,85118.57664,percent of total billed charges,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-10,NDC,outpatient,5,ML,20.56,14.392,AETNA [1000108],AETNA [100010801],,,76.8,,15.79,0.222255,85118.57664,percent of total billed charges,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-05,NDC,outpatient,5,ML,10.16,7.112,AETNA [1000108],AETNA [100010801],,,76.8,,7.8,0.222255,85118.57664,percent of total billed charges,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-41,NDC,outpatient,5,ML,10.16,7.112,AETNA [1000108],AETNA [100010801],,,76.8,,7.8,0.222255,85118.57664,percent of total billed charges,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-01,NDC,outpatient,5,ML,9.31,6.517,AETNA [1000108],AETNA [100010801],,,76.8,,7.15,0.222255,85118.57664,percent of total billed charges,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-01,NDC,outpatient,5,ML,20.56,14.392,AETNA [1000108],AETNA [100010801],,,76.8,,15.79,0.222255,85118.57664,percent of total billed charges,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-05,NDC,outpatient,5,ML,9.31,6.517,AETNA [1000108],AETNA [100010801],,,76.8,,7.15,0.222255,85118.57664,percent of total billed charges,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-11,NDC,outpatient,1,UN,3.5,2.45,AETNA [1000108],AETNA [100010801],,,76.8,,2.69,0.222255,85118.57664,percent of total billed charges,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,65862-0641-63,NDC,outpatient,1,UN,1.45,1.015,AETNA [1000108],AETNA [100010801],,,76.8,,1.11,0.222255,85118.57664,percent of total billed charges,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-01,NDC,outpatient,1,UN,3.5,2.45,AETNA [1000108],AETNA [100010801],,,76.8,,2.69,0.222255,85118.57664,percent of total billed charges,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-01,NDC,outpatient,5,ML,94.7,66.29,AETNA [1000108],AETNA [100010801],,,76.8,,72.73,0.222255,85118.57664,percent of total billed charges,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,54482-0147-01,NDC,outpatient,5,ML,99.51,69.657,AETNA [1000108],AETNA [100010801],,,76.8,,76.42,0.222255,85118.57664,percent of total billed charges,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-10,NDC,outpatient,5,ML,94.7,66.29,AETNA [1000108],AETNA [100010801],,,76.8,,72.73,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 2.5 MG ORAL TABS,RX-21057,CDM,S5000,HCPCS,259,RC,00904-6283-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-01,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-11,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,62756-0184-88,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CITALOPRAM HYDROBROMIDE 20 MG ORAL TABS,RX-21062,CDM,S5000,HCPCS,259,RC,00904-6085-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG ORAL TABS,RX-21284,CDM,S5000,HCPCS,259,RC,42806-0339-01,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-11,NDC,outpatient,1,UN,3.34,2.338,AETNA [1000108],AETNA [100010801],,,76.8,,2.57,0.222255,85118.57664,percent of total billed charges,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-21,NDC,outpatient,1,UN,3.34,2.338,AETNA [1000108],AETNA [100010801],,,76.8,,2.57,0.222255,85118.57664,percent of total billed charges,
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG ORAL TABS,RX-21289,CDM,S5000,HCPCS,259,RC,68462-0334-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG ORAL TABS,RX-21290,CDM,S5000,HCPCS,259,RC,00904-6704-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,60505-0033-06,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,00904-5448-61,NDC,outpatient,1,UN,1.11,0.777,AETNA [1000108],AETNA [100010801],,,76.8,,0.85,0.222255,85118.57664,percent of total billed charges,
DAPSONE 100 MG ORAL TABS,RX-2131,CDM,S5000,HCPCS,259,RC,70954-0136-10,NDC,outpatient,1,UN,5.05,3.535,AETNA [1000108],AETNA [100010801],,,76.8,,3.88,0.222255,85118.57664,percent of total billed charges,
DAPSONE 25 MG ORAL TABS,RX-2132,CDM,S5000,HCPCS,259,RC,70954-0135-10,NDC,outpatient,1,UN,4.35,3.045,AETNA [1000108],AETNA [100010801],,,76.8,,3.34,0.222255,85118.57664,percent of total billed charges,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,00078-0249-15,NDC,outpatient,1,UN,108.93,76.251,AETNA [1000108],AETNA [100010801],,,76.8,,83.66,0.222255,85118.57664,percent of total billed charges,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,59651-0180-30,NDC,outpatient,1,UN,1.55,1.085,AETNA [1000108],AETNA [100010801],,,76.8,,1.19,0.222255,85118.57664,percent of total billed charges,
CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR,RX-21672,CDM,S5000,HCPCS,250,RC,24338-0050-08,NDC,outpatient,8,UN,110831.48,77582.036,AETNA [1000108],AETNA [100010801],,,76.8,,85118.58,0.222255,85118.57664,percent of total billed charges,
ROPINIROLE HCL 0.25 MG ORAL TABS,RX-21688,CDM,S5000,HCPCS,259,RC,00904-6373-61,NDC,outpatient,1,UN,1.51,1.057,AETNA [1000108],AETNA [100010801],,,76.8,,1.16,0.222255,85118.57664,percent of total billed charges,
ROPINIROLE HCL 1 MG ORAL TABS,RX-21689,CDM,S5000,HCPCS,259,RC,00904-6374-61,NDC,outpatient,1,UN,1.76,1.232,AETNA [1000108],AETNA [100010801],,,76.8,,1.35,0.222255,85118.57664,percent of total billed charges,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-11,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-15,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,00904-6638-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
QUETIAPINE FUMARATE 100 MG ORAL TABS,RX-21824,CDM,S5000,HCPCS,259,RC,00904-6640-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TIAGABINE HCL 4 MG ORAL TABS,RX-21827,CDM,S5000,HCPCS,259,RC,62756-0224-83,NDC,outpatient,1,UN,16.11,11.277,AETNA [1000108],AETNA [100010801],,,76.8,,12.37,0.222255,85118.57664,percent of total billed charges,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,31722-0730-90,NDC,outpatient,1,UN,1.91,1.337,AETNA [1000108],AETNA [100010801],,,76.8,,1.47,0.222255,85118.57664,percent of total billed charges,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,33342-0048-10,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
CLOPIDOGREL BISULFATE 75 MG ORAL TABS,RX-22142,CDM,S5000,HCPCS,259,RC,00904-6294-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-11,NDC,outpatient,1,UN,23.4,16.38,AETNA [1000108],AETNA [100010801],,,76.8,,17.97,0.222255,85118.57664,percent of total billed charges,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-21,NDC,outpatient,1,UN,23.4,16.38,AETNA [1000108],AETNA [100010801],,,76.8,,17.97,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-13,NDC,outpatient,1,UN,40.12,28.084,AETNA [1000108],AETNA [100010801],,,76.8,,30.81,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-03,NDC,outpatient,1,UN,40.12,28.084,AETNA [1000108],AETNA [100010801],,,76.8,,30.81,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-56,NDC,outpatient,5,ML,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-04,NDC,outpatient,5,ML,27.71,19.397,AETNA [1000108],AETNA [100010801],,,76.8,,21.28,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-44,NDC,outpatient,5,ML,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,0.222255,85118.57664,percent of total billed charges,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-56,NDC,outpatient,5,ML,27.71,19.397,AETNA [1000108],AETNA [100010801],,,76.8,,21.28,0.222255,85118.57664,percent of total billed charges,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,68462-0564-17,NDC,outpatient,15,GR,861.28,602.896,AETNA [1000108],AETNA [100010801],,,76.8,,661.46,0.222255,85118.57664,percent of total billed charges,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,51672-1370-01,NDC,outpatient,15,GR,62.62,43.834,AETNA [1000108],AETNA [100010801],,,76.8,,48.09,0.222255,85118.57664,percent of total billed charges,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,70756-0609-15,NDC,outpatient,5,ML,31.29,21.903,AETNA [1000108],AETNA [100010801],,,76.8,,24.03,0.222255,85118.57664,percent of total billed charges,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,24208-0410-05,NDC,outpatient,5,ML,214.49,150.143,AETNA [1000108],AETNA [100010801],,,76.8,,164.73,0.222255,85118.57664,percent of total billed charges,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-50,NDC,outpatient,1,UN,1.55,1.085,AETNA [1000108],AETNA [100010801],,,76.8,,1.19,0.222255,85118.57664,percent of total billed charges,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,00904-5224-52,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-25,NDC,outpatient,1,UN,1.55,1.085,AETNA [1000108],AETNA [100010801],,,76.8,,1.19,0.222255,85118.57664,percent of total billed charges,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-61,NDC,outpatient,1,UN,1.44,1.008,AETNA [1000108],AETNA [100010801],,,76.8,,1.11,0.222255,85118.57664,percent of total billed charges,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-06,NDC,outpatient,1,UN,1.19,0.833,AETNA [1000108],AETNA [100010801],,,76.8,,0.91,0.222255,85118.57664,percent of total billed charges,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-11,NDC,outpatient,1,UN,2.8,1.96,AETNA [1000108],AETNA [100010801],,,76.8,,2.15,0.222255,85118.57664,percent of total billed charges,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-15,NDC,outpatient,1,UN,2.8,1.96,AETNA [1000108],AETNA [100010801],,,76.8,,2.15,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,99999-0002-45,NDC,outpatient,20,ML,22.52,15.764,AETNA [1000108],AETNA [100010801],,,76.8,,17.3,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-40,NDC,outpatient,20,ML,60.61,42.427,AETNA [1000108],AETNA [100010801],,,76.8,,46.55,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-20,NDC,outpatient,20,ML,60.61,42.427,AETNA [1000108],AETNA [100010801],,,76.8,,46.55,0.222255,85118.57664,percent of total billed charges,
REPAGLINIDE 2 MG ORAL TABS,RX-22585,CDM,S5000,HCPCS,259,RC,65862-0672-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
REPAGLINIDE 1 MG ORAL TABS,RX-22586,CDM,S5000,HCPCS,259,RC,65862-0671-01,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,60258-0003-16,NDC,outpatient,10,ML,5.88,4.116,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,99999-0002-34,NDC,outpatient,15,ML,3.14,2.198,AETNA [1000108],AETNA [100010801],,,76.8,,2.41,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,00121-0676-16,NDC,outpatient,15,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.222255,85118.57664,percent of total billed charges,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-11,NDC,outpatient,1,UN,6.99,4.893,AETNA [1000108],AETNA [100010801],,,76.8,,5.37,0.222255,85118.57664,percent of total billed charges,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-21,NDC,outpatient,1,UN,6.99,4.893,AETNA [1000108],AETNA [100010801],,,76.8,,5.37,0.222255,85118.57664,percent of total billed charges,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,00904-6890-04,NDC,outpatient,1,UN,10.99,7.693,AETNA [1000108],AETNA [100010801],,,76.8,,8.44,0.222255,85118.57664,percent of total billed charges,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,68462-0473-01,NDC,outpatient,1,UN,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.222255,85118.57664,percent of total billed charges,
DESIPRAMINE HCL 25 MG ORAL TABS,RX-2286,CDM,S5000,HCPCS,259,RC,50742-0113-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,70954-0319-10,NDC,outpatient,5,ML,32.69,22.883,AETNA [1000108],AETNA [100010801],,,76.8,,25.11,0.222255,85118.57664,percent of total billed charges,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,99999-0001-34,NDC,outpatient,10,ML,72.98,51.086,AETNA [1000108],AETNA [100010801],,,76.8,,56.05,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,65862-0946-01,NDC,outpatient,10,ML,89,62.3,AETNA [1000108],AETNA [100010801],,,76.8,,68.35,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,70069-0051-01,NDC,outpatient,10,ML,38.99,27.293,AETNA [1000108],AETNA [100010801],,,76.8,,29.94,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,24208-0486-10,NDC,outpatient,10,ML,45.62,31.934,AETNA [1000108],AETNA [100010801],,,76.8,,35.04,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,82584-0605-10,NDC,outpatient,10,ML,996.05,697.235,AETNA [1000108],AETNA [100010801],,,76.8,,764.97,0.222255,85118.57664,percent of total billed charges,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,71921-0226-10,NDC,outpatient,10,ML,45.39,31.773,AETNA [1000108],AETNA [100010801],,,76.8,,34.86,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,42571-0160-30,NDC,outpatient,1,UN,9.65,6.755,AETNA [1000108],AETNA [100010801],,,76.8,,7.41,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,00781-1874-31,NDC,outpatient,1,UN,6.58,4.606,AETNA [1000108],AETNA [100010801],,,76.8,,5.05,0.222255,85118.57664,percent of total billed charges,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,16729-0073-29,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,00004-1101-50,NDC,outpatient,1,UN,195.05,136.535,AETNA [1000108],AETNA [100010801],,,76.8,,149.8,0.222255,85118.57664,percent of total billed charges,
RISEDRONATE SODIUM 30 MG ORAL TABS,RX-23015,CDM,S5000,HCPCS,259,RC,00093-3100-56,NDC,outpatient,1,UN,220.55,154.385,AETNA [1000108],AETNA [100010801],,,76.8,,169.38,0.222255,85118.57664,percent of total billed charges,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,00536-1268-12,NDC,outpatient,222,ML,16.8,11.76,AETNA [1000108],AETNA [100010801],,,76.8,,12.9,0.222255,85118.57664,percent of total billed charges,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,46122-0573-10,NDC,outpatient,222,ML,11.13,7.791,AETNA [1000108],AETNA [100010801],,,76.8,,8.55,0.222255,85118.57664,percent of total billed charges,
CLINISOL SF 15 % IV SOLN,RX-23068,CDM,S5000,HCPCS,250,RC,00338-0502-06,NDC,outpatient,2000,ML,211.8,148.26,AETNA [1000108],AETNA [100010801],,,76.8,,162.66,0.222255,85118.57664,percent of total billed charges,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1123-04,NDC,outpatient,2000,ML,211.8,148.26,AETNA [1000108],AETNA [100010801],,,76.8,,162.66,0.222255,85118.57664,percent of total billed charges,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1147-03,NDC,outpatient,1000,ML,122.8,85.96,AETNA [1000108],AETNA [100010801],,,76.8,,94.31,0.222255,85118.57664,percent of total billed charges,
DEXAMETHASONE 0.5 MG ORAL TABS,RX-2322,CDM,S5000,HCPCS,259,RC,00054-8179-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,62332-0341-90,NDC,outpatient,1,UN,4.08,2.856,AETNA [1000108],AETNA [100010801],,,76.8,,3.13,0.222255,85118.57664,percent of total billed charges,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,33342-0114-07,NDC,outpatient,1,UN,5.64,3.948,AETNA [1000108],AETNA [100010801],,,76.8,,4.33,0.222255,85118.57664,percent of total billed charges,
CANDESARTAN CILEXETIL 16 MG ORAL TABS,RX-23231,CDM,S5000,HCPCS,259,RC,33342-0116-07,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,
DEXAMETHASONE 1 MG ORAL TABS,RX-2324,CDM,S5000,HCPCS,259,RC,00054-8174-25,NDC,outpatient,1,UN,1.46,1.022,AETNA [1000108],AETNA [100010801],,,76.8,,1.12,0.222255,85118.57664,percent of total billed charges,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-51,NDC,outpatient,1,UN,4.47,3.129,AETNA [1000108],AETNA [100010801],,,76.8,,3.43,0.222255,85118.57664,percent of total billed charges,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-80,NDC,outpatient,1,UN,4.47,3.129,AETNA [1000108],AETNA [100010801],,,76.8,,3.43,0.222255,85118.57664,percent of total billed charges,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,00054-8175-25,NDC,outpatient,1,UN,4.2,2.94,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,
DEXAMETHASONE 6 MG ORAL TABS,RX-2328,CDM,S5000,HCPCS,259,RC,00054-8183-25,NDC,outpatient,1,UN,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,S5000,HCPCS,259,RC,24208-0720-02,NDC,outpatient,5,ML,228.82,160.174,AETNA [1000108],AETNA [100010801],,,76.8,,175.73,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-05,NDC,outpatient,5,GR,12.51,8.757,AETNA [1000108],AETNA [100010801],,,76.8,,9.61,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,39328-0024-30,NDC,outpatient,30,GR,40.32,28.224,AETNA [1000108],AETNA [100010801],,,76.8,,30.97,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-06,NDC,outpatient,5,GR,12.51,8.757,AETNA [1000108],AETNA [100010801],,,76.8,,9.61,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-02,NDC,outpatient,250,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,S5000,HCPCS,250,RC,00990-7935-19,NDC,outpatient,500,ML,62.73,43.911,AETNA [1000108],AETNA [100010801],,,76.8,,48.18,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,S5000,HCPCS,250,RC,00409-1775-10,NDC,outpatient,10,ML,57.77,40.439,AETNA [1000108],AETNA [100010801],,,76.8,,44.37,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69623-0201-39,NDC,outpatient,50,ML,93.45,65.415,AETNA [1000108],AETNA [100010801],,,76.8,,71.77,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-64,NDC,outpatient,50,ML,59.41,41.587,AETNA [1000108],AETNA [100010801],,,76.8,,45.63,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-02,NDC,outpatient,50,ML,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69374-0953-50,NDC,outpatient,50,ML,66.75,46.725,AETNA [1000108],AETNA [100010801],,,76.8,,51.26,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,76329-3302-01,NDC,outpatient,50,ML,66.31,46.417,AETNA [1000108],AETNA [100010801],,,76.8,,50.93,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-34,NDC,outpatient,50,ML,59.41,41.587,AETNA [1000108],AETNA [100010801],,,76.8,,45.63,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-16,NDC,outpatient,50,ML,31.82,22.274,AETNA [1000108],AETNA [100010801],,,76.8,,24.44,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-16,NDC,outpatient,50,ML,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,0.222255,85118.57664,percent of total billed charges,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-66,NDC,outpatient,50,ML,58.08,40.656,AETNA [1000108],AETNA [100010801],,,76.8,,44.61,0.222255,85118.57664,percent of total billed charges,
EFAVIRENZ 200 MG ORAL CAPS,RX-23900,CDM,S5000,HCPCS,259,RC,64980-0407-09,NDC,outpatient,1,UN,33.64,23.548,AETNA [1000108],AETNA [100010801],,,76.8,,25.84,0.222255,85118.57664,percent of total billed charges,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,00172-3925-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MICONAZOLE NITRATE 4 % VA CREA,RX-24050,CDM,S5000,HCPCS,259,RC,63736-0442-01,NDC,outpatient,15,GR,44.73,31.311,AETNA [1000108],AETNA [100010801],,,76.8,,34.35,0.222255,85118.57664,percent of total billed charges,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,59651-0565-01,NDC,outpatient,1,UN,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,00093-3123-01,NDC,outpatient,1,UN,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-59,NDC,outpatient,5,ML,21.65,15.155,AETNA [1000108],AETNA [100010801],,,76.8,,16.63,0.222255,85118.57664,percent of total billed charges,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-62,NDC,outpatient,5,ML,21.65,15.155,AETNA [1000108],AETNA [100010801],,,76.8,,16.63,0.222255,85118.57664,percent of total billed charges,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-11,NDC,outpatient,1,UN,1.75,1.225,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-01,NDC,outpatient,1,UN,1.75,1.225,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-11,NDC,outpatient,1,UN,1.8,1.26,AETNA [1000108],AETNA [100010801],,,76.8,,1.38,0.222255,85118.57664,percent of total billed charges,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-01,NDC,outpatient,1,UN,1.8,1.26,AETNA [1000108],AETNA [100010801],,,76.8,,1.38,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,00536-1248-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,63739-0432-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ISOSORBIDE MONONITRATE ER 60 MG ORAL TAB,RX-24268,CDM,S5000,HCPCS,259,RC,00904-6450-61,NDC,outpatient,1,UN,1.31,0.917,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,
TELMISARTAN 40 MG ORAL TABS,RX-24335,CDM,S5000,HCPCS,259,RC,00597-0040-37,NDC,outpatient,1,UN,19.23,13.461,AETNA [1000108],AETNA [100010801],,,76.8,,14.77,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,S5000,HCPCS,259,RC,51672-3007-01,NDC,outpatient,10,ML,303.14,212.198,AETNA [1000108],AETNA [100010801],,,76.8,,232.81,0.222255,85118.57664,percent of total billed charges,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,00378-4105-91,NDC,outpatient,1,UN,13.01,9.107,AETNA [1000108],AETNA [100010801],,,76.8,,9.99,0.222255,85118.57664,percent of total billed charges,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-21,NDC,outpatient,1,UN,26.71,18.697,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-11,NDC,outpatient,1,UN,26.71,18.697,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,
DIGOXIN 125 MCG ORAL TABS,RX-2444,CDM,S5000,HCPCS,259,RC,00904-5921-61,NDC,outpatient,1,UN,3.14,2.198,AETNA [1000108],AETNA [100010801],,,76.8,,2.41,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-61,NDC,outpatient,1,UN,5.08,3.556,AETNA [1000108],AETNA [100010801],,,76.8,,3.9,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-04,NDC,outpatient,1,UN,7.7,5.39,AETNA [1000108],AETNA [100010801],,,76.8,,5.91,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-01,NDC,outpatient,1,UN,4.79,3.353,AETNA [1000108],AETNA [100010801],,,76.8,,3.68,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-11,NDC,outpatient,1,UN,4.79,3.353,AETNA [1000108],AETNA [100010801],,,76.8,,3.68,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,63739-0548-33,NDC,outpatient,1,UN,5.24,3.668,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.222255,85118.57664,percent of total billed charges,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-11,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-15,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,00904-6502-61,NDC,outpatient,1,UN,3.56,2.492,AETNA [1000108],AETNA [100010801],,,76.8,,2.73,0.222255,85118.57664,percent of total billed charges,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-01,NDC,outpatient,1,UN,3.16,2.212,AETNA [1000108],AETNA [100010801],,,76.8,,2.43,0.222255,85118.57664,percent of total billed charges,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-11,NDC,outpatient,1,UN,3.16,2.212,AETNA [1000108],AETNA [100010801],,,76.8,,2.43,0.222255,85118.57664,percent of total billed charges,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,00904-6503-61,NDC,outpatient,1,UN,5.49,3.843,AETNA [1000108],AETNA [100010801],,,76.8,,4.22,0.222255,85118.57664,percent of total billed charges,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,60505-3849-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
ISOSORBIDE MONONITRATE ER 30 MG ORAL TB24,RX-24521,CDM,S5000,HCPCS,259,RC,00904-6449-61,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-11,NDC,outpatient,1,UN,25.83,18.081,AETNA [1000108],AETNA [100010801],,,76.8,,19.84,0.222255,85118.57664,percent of total billed charges,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-11,NDC,outpatient,1,UN,21.38,14.966,AETNA [1000108],AETNA [100010801],,,76.8,,16.42,0.222255,85118.57664,percent of total billed charges,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-21,NDC,outpatient,1,UN,21.38,14.966,AETNA [1000108],AETNA [100010801],,,76.8,,16.42,0.222255,85118.57664,percent of total billed charges,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,00904-6791-04,NDC,outpatient,1,UN,21.38,14.966,AETNA [1000108],AETNA [100010801],,,76.8,,16.42,0.222255,85118.57664,percent of total billed charges,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-12,NDC,outpatient,1,UN,25.83,18.081,AETNA [1000108],AETNA [100010801],,,76.8,,19.84,0.222255,85118.57664,percent of total billed charges,
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,S5000,HCPCS,259,RC,00574-7040-12,NDC,outpatient,1,UN,104.53,73.171,AETNA [1000108],AETNA [100010801],,,76.8,,80.28,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,00093-0318-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-01,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-11,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,
DIMENHYDRINATE 50 MG ORAL TABS,RX-2485,CDM,S5000,HCPCS,259,RC,00904-2051-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TACROLIMUS 0.5 MG ORAL CAPS,RX-24914,CDM,S5000,HCPCS,259,RC,00904-6623-61,NDC,outpatient,1,UN,2.82,1.974,AETNA [1000108],AETNA [100010801],,,76.8,,2.17,0.222255,85118.57664,percent of total billed charges,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-01,NDC,outpatient,3,ML,5.32,3.724,AETNA [1000108],AETNA [100010801],,,76.8,,4.09,0.222255,85118.57664,percent of total billed charges,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-11,NDC,outpatient,3,ML,5.32,3.724,AETNA [1000108],AETNA [100010801],,,76.8,,4.09,0.222255,85118.57664,percent of total billed charges,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-45,NDC,outpatient,3,ML,7.12,4.984,AETNA [1000108],AETNA [100010801],,,76.8,,5.47,0.222255,85118.57664,percent of total billed charges,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-56,NDC,outpatient,3,ML,7.12,4.984,AETNA [1000108],AETNA [100010801],,,76.8,,5.47,0.222255,85118.57664,percent of total billed charges,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-01,NDC,outpatient,3,ML,5.47,3.829,AETNA [1000108],AETNA [100010801],,,76.8,,4.2,0.222255,85118.57664,percent of total billed charges,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-11,NDC,outpatient,3,ML,5.47,3.829,AETNA [1000108],AETNA [100010801],,,76.8,,4.2,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-55,NDC,outpatient,3,ML,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-52,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-31,NDC,outpatient,3,ML,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-79,NDC,outpatient,3,ML,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-83,NDC,outpatient,3,ML,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-48,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-01,NDC,outpatient,3,ML,1.18,0.826,AETNA [1000108],AETNA [100010801],,,76.8,,0.91,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00487-9501-01,NDC,outpatient,3,ML,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-49,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-60,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,99999-0002-21,NDC,outpatient,2.5,ML,69.2,48.44,AETNA [1000108],AETNA [100010801],,,76.8,,53.15,0.222255,85118.57664,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,66689-0307-08,NDC,outpatient,160,ML,1111.44,778.008,AETNA [1000108],AETNA [100010801],,,76.8,,853.59,0.222255,85118.57664,percent of total billed charges,
DIPHENHYDRAMINE HCL 25 MG ORAL CAPS,RX-2509,CDM,S5000,HCPCS,259,RC,00904-7237-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-05,NDC,outpatient,5,ML,15.4,10.78,AETNA [1000108],AETNA [100010801],,,76.8,,11.83,0.222255,85118.57664,percent of total billed charges,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-00,NDC,outpatient,5,ML,15.4,10.78,AETNA [1000108],AETNA [100010801],,,76.8,,11.83,0.222255,85118.57664,percent of total billed charges,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,62135-0308-01,NDC,outpatient,1,UN,12.1,8.47,AETNA [1000108],AETNA [100010801],,,76.8,,9.29,0.222255,85118.57664,percent of total billed charges,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,65862-0076-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,00143-9927-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,00406-1236-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,69315-0910-01,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,99999-0003-98,NDC,outpatient,5,ML,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,00472-0825-16,NDC,outpatient,5,ML,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,70752-0102-12,NDC,outpatient,5,ML,1.91,1.337,AETNA [1000108],AETNA [100010801],,,76.8,,1.47,0.222255,85118.57664,percent of total billed charges,
DIPYRIDAMOLE 25 MG ORAL TABS,RX-2528,CDM,S5000,HCPCS,259,RC,64980-0133-01,NDC,outpatient,1,UN,5.27,3.689,AETNA [1000108],AETNA [100010801],,,76.8,,4.05,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-25,NDC,outpatient,1,UN,27.72,19.404,AETNA [1000108],AETNA [100010801],,,76.8,,21.29,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-95,NDC,outpatient,1,UN,27.72,19.404,AETNA [1000108],AETNA [100010801],,,76.8,,21.29,0.222255,85118.57664,percent of total billed charges,
DISOPYRAMIDE PHOSPHATE 100 MG ORAL CAPS,RX-2535,CDM,S5000,HCPCS,259,RC,00093-3127-01,NDC,outpatient,1,UN,5.28,3.696,AETNA [1000108],AETNA [100010801],,,76.8,,4.06,0.222255,85118.57664,percent of total billed charges,
DISULFIRAM 250 MG ORAL TABS,RX-2540,CDM,S5000,HCPCS,259,RC,47781-0607-30,NDC,outpatient,1,UN,7.69,5.383,AETNA [1000108],AETNA [100010801],,,76.8,,5.91,0.222255,85118.57664,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-86,NDC,outpatient,1,UN,3.67,2.569,AETNA [1000108],AETNA [100010801],,,76.8,,2.82,0.222255,85118.57664,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-10,NDC,outpatient,1,UN,3.43,2.401,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-81,NDC,outpatient,1,UN,3.67,2.569,AETNA [1000108],AETNA [100010801],,,76.8,,2.82,0.222255,85118.57664,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-17,NDC,outpatient,1,UN,3.43,2.401,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-21,NDC,outpatient,1,UN,3.46,2.422,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-11,NDC,outpatient,1,UN,3.46,2.422,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68382-0112-14,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 0.5 MG ORAL TABS,RX-25520,CDM,S5000,HCPCS,259,RC,00904-7361-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-11,NDC,outpatient,1,UN,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-01,NDC,outpatient,1,UN,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-11,NDC,outpatient,1,UN,1.16,0.812,AETNA [1000108],AETNA [100010801],,,76.8,,0.89,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-61,NDC,outpatient,1,UN,1.16,0.812,AETNA [1000108],AETNA [100010801],,,76.8,,0.89,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,00904-6861-90,NDC,outpatient,1,UN,1.2,0.84,AETNA [1000108],AETNA [100010801],,,76.8,,0.92,0.222255,85118.57664,percent of total billed charges,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7183-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-80,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,00006-0032-20,NDC,outpatient,1,UN,19.14,13.398,AETNA [1000108],AETNA [100010801],,,76.8,,14.7,0.222255,85118.57664,percent of total billed charges,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,42799-0806-01,NDC,outpatient,1,UN,14.59,10.213,AETNA [1000108],AETNA [100010801],,,76.8,,11.21,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-01,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,00904-7052-61,NDC,outpatient,1,UN,2.19,1.533,AETNA [1000108],AETNA [100010801],,,76.8,,1.68,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-20,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-20,NDC,outpatient,1,UN,6.84,4.788,AETNA [1000108],AETNA [100010801],,,76.8,,5.25,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,00378-6410-01,NDC,outpatient,1,UN,5.48,3.836,AETNA [1000108],AETNA [100010801],,,76.8,,4.21,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-01,NDC,outpatient,1,UN,6.84,4.788,AETNA [1000108],AETNA [100010801],,,76.8,,5.25,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,00378-3125-01,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-01,NDC,outpatient,1,UN,2.89,2.023,AETNA [1000108],AETNA [100010801],,,76.8,,2.22,0.222255,85118.57664,percent of total billed charges,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-20,NDC,outpatient,1,UN,2.89,2.023,AETNA [1000108],AETNA [100010801],,,76.8,,2.22,0.222255,85118.57664,percent of total billed charges,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,57896-0116-03,NDC,outpatient,85,GR,10.97,7.679,AETNA [1000108],AETNA [100010801],,,76.8,,8.42,0.222255,85118.57664,percent of total billed charges,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1101-45,NDC,outpatient,85,GR,10.6,7.42,AETNA [1000108],AETNA [100010801],,,76.8,,8.14,0.222255,85118.57664,percent of total billed charges,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1349-57,NDC,outpatient,85,GR,9.08,6.356,AETNA [1000108],AETNA [100010801],,,76.8,,6.97,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-10,NDC,outpatient,1,UN,49.76,34.832,AETNA [1000108],AETNA [100010801],,,76.8,,38.22,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-00,NDC,outpatient,1,UN,68.55,47.985,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-10,NDC,outpatient,1,UN,107.52,75.264,AETNA [1000108],AETNA [100010801],,,76.8,,82.58,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-01,NDC,outpatient,1,UN,49.76,34.832,AETNA [1000108],AETNA [100010801],,,76.8,,38.22,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-11,NDC,outpatient,1,UN,45.64,31.948,AETNA [1000108],AETNA [100010801],,,76.8,,35.05,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-01,NDC,outpatient,1,UN,107.52,75.264,AETNA [1000108],AETNA [100010801],,,76.8,,82.58,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-02,NDC,outpatient,1,UN,45.64,31.948,AETNA [1000108],AETNA [100010801],,,76.8,,35.05,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-10,NDC,outpatient,1,UN,68.55,47.985,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.222255,85118.57664,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-51,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,00904-6474-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-80,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00143-2112-50,NDC,outpatient,1,UN,1.07,0.749,AETNA [1000108],AETNA [100010801],,,76.8,,0.82,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00904-0430-06,NDC,outpatient,1,UN,5.29,3.703,AETNA [1000108],AETNA [100010801],,,76.8,,4.06,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-11,NDC,outpatient,1,UN,4.84,3.388,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-21,NDC,outpatient,1,UN,4.84,3.388,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.222255,85118.57664,percent of total billed charges,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-11,NDC,outpatient,1,UN,4.16,2.912,AETNA [1000108],AETNA [100010801],,,76.8,,3.19,0.222255,85118.57664,percent of total billed charges,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-01,NDC,outpatient,1,UN,4.16,2.912,AETNA [1000108],AETNA [100010801],,,76.8,,3.19,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,31722-0632-31,NDC,outpatient,1,UN,4.28,2.996,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,64380-0799-01,NDC,outpatient,1,UN,8.24,5.768,AETNA [1000108],AETNA [100010801],,,76.8,,6.33,0.222255,85118.57664,percent of total billed charges,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-11,NDC,outpatient,1,UN,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.222255,85118.57664,percent of total billed charges,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-21,NDC,outpatient,1,UN,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.222255,85118.57664,percent of total billed charges,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,27241-0049-10,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
EXEMESTANE 25 MG ORAL TABS,RX-26551,CDM,S5000,HCPCS,259,RC,59762-2858-01,NDC,outpatient,1,UN,6.65,4.655,AETNA [1000108],AETNA [100010801],,,76.8,,5.11,0.222255,85118.57664,percent of total billed charges,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,00904-7124-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,65862-0246-08,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MOXIFLOXACIN HCL 400 MG ORAL TABS,RX-26854,CDM,S5000,HCPCS,259,RC,65862-0603-30,NDC,outpatient,1,UN,13.67,9.569,AETNA [1000108],AETNA [100010801],,,76.8,,10.5,0.222255,85118.57664,percent of total billed charges,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,69452-0131-17,NDC,outpatient,1,UN,2.23,1.561,AETNA [1000108],AETNA [100010801],,,76.8,,1.71,0.222255,85118.57664,percent of total billed charges,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,72205-0039-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,16729-0490-12,NDC,outpatient,1,UN,6.58,4.606,AETNA [1000108],AETNA [100010801],,,76.8,,5.05,0.222255,85118.57664,percent of total billed charges,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,00904-6682-08,NDC,outpatient,1,UN,13.18,9.226,AETNA [1000108],AETNA [100010801],,,76.8,,10.12,0.222255,85118.57664,percent of total billed charges,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,42291-0412-60,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,69452-0132-17,NDC,outpatient,1,UN,2.23,1.561,AETNA [1000108],AETNA [100010801],,,76.8,,1.71,0.222255,85118.57664,percent of total billed charges,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,00904-6683-08,NDC,outpatient,1,UN,13.31,9.317,AETNA [1000108],AETNA [100010801],,,76.8,,10.22,0.222255,85118.57664,percent of total billed charges,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,42291-0413-60,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
TERBINAFINE HCL 1 % EX CREA,RX-27023,CDM,S5000,HCPCS,259,RC,51672-2080-01,NDC,outpatient,15,GR,24.57,17.199,AETNA [1000108],AETNA [100010801],,,76.8,,18.87,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,S5000,HCPCS,259,RC,11980-0174-05,NDC,outpatient,5,ML,659.54,461.678,AETNA [1000108],AETNA [100010801],,,76.8,,506.53,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-01,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-11,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,
CHARCOAL ACTIVATED ORAL LIQD,RX-27099,CDM,S5000,HCPCS,259,RC,66689-0202-04,NDC,outpatient,120,ML,82.77,57.939,AETNA [1000108],AETNA [100010801],,,76.8,,63.57,0.222255,85118.57664,percent of total billed charges,
RISEDRONATE SODIUM 5 MG ORAL TABS,RX-27112,CDM,S5000,HCPCS,259,RC,33342-0107-07,NDC,outpatient,1,UN,11.13,7.791,AETNA [1000108],AETNA [100010801],,,76.8,,8.55,0.222255,85118.57664,percent of total billed charges,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,59651-0018-90,NDC,outpatient,1,UN,1.7,1.19,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,47335-0539-81,NDC,outpatient,1,UN,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-1210-01,NDC,outpatient,454,GR,8.09,5.663,AETNA [1000108],AETNA [100010801],,,76.8,,6.21,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,49580-0394-04,NDC,outpatient,1814,GR,16.15,11.305,AETNA [1000108],AETNA [100010801],,,76.8,,12.4,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-0038-01,NDC,outpatient,454,GR,8.09,5.663,AETNA [1000108],AETNA [100010801],,,76.8,,6.21,0.222255,85118.57664,percent of total billed charges,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-02,NDC,outpatient,2,ML,34.38,24.066,AETNA [1000108],AETNA [100010801],,,76.8,,26.4,0.222255,85118.57664,percent of total billed charges,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-10,NDC,outpatient,10,ML,39.03,27.321,AETNA [1000108],AETNA [100010801],,,76.8,,29.98,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE ER 100 MG ORAL CP24,RX-27418,CDM,S5000,HCPCS,259,RC,52244-0100-10,NDC,outpatient,1,UN,14.48,10.136,AETNA [1000108],AETNA [100010801],,,76.8,,11.12,0.222255,85118.57664,percent of total billed charges,
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,S5000,HCPCS,250,RC,63323-0113-10,NDC,outpatient,1,UN,686.14,480.298,AETNA [1000108],AETNA [100010801],,,76.8,,526.96,0.222255,85118.57664,percent of total billed charges,
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,S5000,HCPCS,259,RC,55566-2800-01,NDC,outpatient,1,UN,2100.63,1470.441,AETNA [1000108],AETNA [100010801],,,76.8,,1613.28,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-16,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-93,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-16,NDC,outpatient,1,UN,2.2,1.54,AETNA [1000108],AETNA [100010801],,,76.8,,1.69,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-93,NDC,outpatient,1,UN,2.2,1.54,AETNA [1000108],AETNA [100010801],,,76.8,,1.69,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-30,NDC,outpatient,1,UN,217.89,152.523,AETNA [1000108],AETNA [100010801],,,76.8,,167.34,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-01,NDC,outpatient,1,UN,217.89,152.523,AETNA [1000108],AETNA [100010801],,,76.8,,167.34,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-93,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-16,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,43598-0894-30,NDC,outpatient,1,UN,9.32,6.524,AETNA [1000108],AETNA [100010801],,,76.8,,7.16,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-16,NDC,outpatient,1,UN,3.17,2.219,AETNA [1000108],AETNA [100010801],,,76.8,,2.43,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-93,NDC,outpatient,1,UN,3.17,2.219,AETNA [1000108],AETNA [100010801],,,76.8,,2.43,0.222255,85118.57664,percent of total billed charges,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,00603-3581-21,NDC,outpatient,1,UN,1.73,1.211,AETNA [1000108],AETNA [100010801],,,76.8,,1.33,0.222255,85118.57664,percent of total billed charges,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,13668-0132-01,NDC,outpatient,1,UN,1.96,1.372,AETNA [1000108],AETNA [100010801],,,76.8,,1.51,0.222255,85118.57664,percent of total billed charges,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,68462-0233-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,00536-1161-37,NDC,outpatient,1,UN,1.77,1.239,AETNA [1000108],AETNA [100010801],,,76.8,,1.36,0.222255,85118.57664,percent of total billed charges,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,63824-0056-34,NDC,outpatient,1,UN,1.93,1.351,AETNA [1000108],AETNA [100010801],,,76.8,,1.48,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-01,NDC,outpatient,1,UN,3.24,2.268,AETNA [1000108],AETNA [100010801],,,76.8,,2.49,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-11,NDC,outpatient,1,UN,3.24,2.268,AETNA [1000108],AETNA [100010801],,,76.8,,2.49,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68382-0106-01,NDC,outpatient,1,UN,1.55,1.085,AETNA [1000108],AETNA [100010801],,,76.8,,1.19,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-11,NDC,outpatient,1,UN,7.06,4.942,AETNA [1000108],AETNA [100010801],,,76.8,,5.42,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-13,NDC,outpatient,1,UN,7.06,4.942,AETNA [1000108],AETNA [100010801],,,76.8,,5.42,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE ER 300 MG ORAL CP12,RX-27633,CDM,S5000,HCPCS,259,RC,66993-0409-32,NDC,outpatient,1,UN,5.66,3.962,AETNA [1000108],AETNA [100010801],,,76.8,,4.35,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE ER 100 MG ORAL TB12,RX-27634,CDM,S5000,HCPCS,259,RC,51672-4123-01,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE ER 400 MG ORAL TB12,RX-27636,CDM,S5000,HCPCS,259,RC,51672-4125-01,NDC,outpatient,1,UN,2.24,1.568,AETNA [1000108],AETNA [100010801],,,76.8,,1.72,0.222255,85118.57664,percent of total billed charges,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,68462-0405-60,NDC,outpatient,1,UN,2.36,1.652,AETNA [1000108],AETNA [100010801],,,76.8,,1.81,0.222255,85118.57664,percent of total billed charges,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,49884-0007-02,NDC,outpatient,1,UN,22.19,15.533,AETNA [1000108],AETNA [100010801],,,76.8,,17.04,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-11,NDC,outpatient,1,UN,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-01,NDC,outpatient,1,UN,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-11,NDC,outpatient,1,UN,11.24,7.868,AETNA [1000108],AETNA [100010801],,,76.8,,8.63,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,62175-0262-37,NDC,outpatient,1,UN,9.51,6.657,AETNA [1000108],AETNA [100010801],,,76.8,,7.3,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-21,NDC,outpatient,1,UN,11.24,7.868,AETNA [1000108],AETNA [100010801],,,76.8,,8.63,0.222255,85118.57664,percent of total billed charges,
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,S5000,HCPCS,259,RC,17238-0900-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,S5000,HCPCS,259,RC,41167-0057-24,NDC,outpatient,141,GR,30.75,21.525,AETNA [1000108],AETNA [100010801],,,76.8,,23.62,0.222255,85118.57664,percent of total billed charges,
DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,RX-27770,CDM,S5000,HCPCS,259,RC,24208-0342-05,NDC,outpatient,5,ML,655.13,458.591,AETNA [1000108],AETNA [100010801],,,76.8,,503.14,0.222255,85118.57664,percent of total billed charges,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-15,NDC,outpatient,1,UN,2.24,1.568,AETNA [1000108],AETNA [100010801],,,76.8,,1.72,0.222255,85118.57664,percent of total billed charges,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-11,NDC,outpatient,1,UN,2.24,1.568,AETNA [1000108],AETNA [100010801],,,76.8,,1.72,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-02,NDC,outpatient,250,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,,,outpatient,500,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-38,NDC,outpatient,100,ML,22.17,15.519,AETNA [1000108],AETNA [100010801],,,76.8,,17.03,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-48,NDC,outpatient,100,ML,22.69,15.883,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00409-7101-67,NDC,outpatient,100,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-41,NDC,outpatient,50,ML,22.94,16.058,AETNA [1000108],AETNA [100010801],,,76.8,,17.62,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-02,NDC,outpatient,250,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-04,NDC,outpatient,500,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00487-4301-10,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-11,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-01,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-11,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,00904-7077-61,NDC,outpatient,1,UN,1.54,1.078,AETNA [1000108],AETNA [100010801],,,76.8,,1.18,0.222255,85118.57664,percent of total billed charges,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-01,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,S5000,HCPCS,259,RC,43598-0446-74,NDC,outpatient,1,UN,4.78,3.346,AETNA [1000108],AETNA [100010801],,,76.8,,3.67,0.222255,85118.57664,percent of total billed charges,
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,S5000,HCPCS,259,RC,43598-0447-74,NDC,outpatient,1,UN,5.28,3.696,AETNA [1000108],AETNA [100010801],,,76.8,,4.06,0.222255,85118.57664,percent of total billed charges,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-33,NDC,outpatient,1,UN,7.5,5.25,AETNA [1000108],AETNA [100010801],,,76.8,,5.76,0.222255,85118.57664,percent of total billed charges,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-88,NDC,outpatient,1,UN,7.5,5.25,AETNA [1000108],AETNA [100010801],,,76.8,,5.76,0.222255,85118.57664,percent of total billed charges,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-28,NDC,outpatient,1,UN,5.25,3.675,AETNA [1000108],AETNA [100010801],,,76.8,,4.03,0.222255,85118.57664,percent of total billed charges,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-74,NDC,outpatient,1,UN,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,00054-3500-49,NDC,outpatient,5,ML,2.23,1.561,AETNA [1000108],AETNA [100010801],,,76.8,,1.71,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,62135-0712-42,NDC,outpatient,5,ML,20.16,14.112,AETNA [1000108],AETNA [100010801],,,76.8,,15.48,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,72888-0125-26,NDC,outpatient,5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,99999-0002-05,NDC,outpatient,15,ML,60.48,42.336,AETNA [1000108],AETNA [100010801],,,76.8,,46.45,0.222255,85118.57664,percent of total billed charges,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-11,NDC,outpatient,1,UN,17.49,12.243,AETNA [1000108],AETNA [100010801],,,76.8,,13.43,0.222255,85118.57664,percent of total billed charges,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-47,NDC,outpatient,1,UN,17.49,12.243,AETNA [1000108],AETNA [100010801],,,76.8,,13.43,0.222255,85118.57664,percent of total billed charges,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-16,NDC,outpatient,1,UN,37.78,26.446,AETNA [1000108],AETNA [100010801],,,76.8,,29.02,0.222255,85118.57664,percent of total billed charges,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-11,NDC,outpatient,1,UN,25.49,17.843,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,0.222255,85118.57664,percent of total billed charges,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-47,NDC,outpatient,1,UN,25.49,17.843,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,0.222255,85118.57664,percent of total billed charges,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-98,NDC,outpatient,1,UN,37.78,26.446,AETNA [1000108],AETNA [100010801],,,76.8,,29.02,0.222255,85118.57664,percent of total billed charges,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-47,NDC,outpatient,1,UN,37.66,26.362,AETNA [1000108],AETNA [100010801],,,76.8,,28.92,0.222255,85118.57664,percent of total billed charges,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-11,NDC,outpatient,1,UN,37.66,26.362,AETNA [1000108],AETNA [100010801],,,76.8,,28.92,0.222255,85118.57664,percent of total billed charges,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-16,NDC,outpatient,1,UN,93.74,65.618,AETNA [1000108],AETNA [100010801],,,76.8,,71.99,0.222255,85118.57664,percent of total billed charges,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-98,NDC,outpatient,1,UN,93.74,65.618,AETNA [1000108],AETNA [100010801],,,76.8,,71.99,0.222255,85118.57664,percent of total billed charges,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-30,NDC,outpatient,1,UN,4.71,3.297,AETNA [1000108],AETNA [100010801],,,76.8,,3.62,0.222255,85118.57664,percent of total billed charges,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-10,NDC,outpatient,1,UN,3.99,2.793,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.222255,85118.57664,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML ORAL SUSP,RX-27999,CDM,S5000,HCPCS,259,RC,46287-0006-60,NDC,outpatient,60,ML,91.85,64.295,AETNA [1000108],AETNA [100010801],,,76.8,,70.54,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,99999-0003-51,NDC,outpatient,2.5,ML,10.37,7.259,AETNA [1000108],AETNA [100010801],,,76.8,,7.96,0.222255,85118.57664,percent of total billed charges,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,16714-0601-02,NDC,outpatient,2.5,ML,10.37,7.259,AETNA [1000108],AETNA [100010801],,,76.8,,7.96,0.222255,85118.57664,percent of total billed charges,
FE FUMARATE-B12-VIT C-FA-IFC ORAL CAPS,RX-28030,CDM,S5000,HCPCS,259,RC,51991-0635-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-02,NDC,outpatient,56,GR,17.7,12.39,AETNA [1000108],AETNA [100010801],,,76.8,,13.59,0.222255,85118.57664,percent of total billed charges,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-01,NDC,outpatient,78,GR,22.91,16.037,AETNA [1000108],AETNA [100010801],,,76.8,,17.59,0.222255,85118.57664,percent of total billed charges,
ASPIRIN BUF(CACARB-MGCARB-MGO) 325 MG ORAL TABS,RX-28122,CDM,S5000,HCPCS,259,RC,00904-2015-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-81,NDC,outpatient,1,UN,3.06,2.142,AETNA [1000108],AETNA [100010801],,,76.8,,2.35,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,60505-3275-00,NDC,outpatient,1,UN,1.9,1.33,AETNA [1000108],AETNA [100010801],,,76.8,,1.46,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-65,NDC,outpatient,1,UN,2.89,2.023,AETNA [1000108],AETNA [100010801],,,76.8,,2.22,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,33342-0083-07,NDC,outpatient,1,UN,3.81,2.667,AETNA [1000108],AETNA [100010801],,,76.8,,2.93,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-79,NDC,outpatient,1,UN,3.06,2.142,AETNA [1000108],AETNA [100010801],,,76.8,,2.35,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-19,NDC,outpatient,1,UN,2.89,2.023,AETNA [1000108],AETNA [100010801],,,76.8,,2.22,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-55,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-52,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-33,NDC,outpatient,1,UN,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.222255,85118.57664,percent of total billed charges,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-84,NDC,outpatient,1,UN,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.222255,85118.57664,percent of total billed charges,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,00904-6553-04,NDC,outpatient,1,UN,7.73,5.411,AETNA [1000108],AETNA [100010801],,,76.8,,5.94,0.222255,85118.57664,percent of total billed charges,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,59762-1308-04,NDC,outpatient,150,ML,1694.12,1185.884,AETNA [1000108],AETNA [100010801],,,76.8,,1301.08,0.222255,85118.57664,percent of total billed charges,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,99999-0002-85,NDC,outpatient,30,ML,340.43,238.301,AETNA [1000108],AETNA [100010801],,,76.8,,261.45,0.222255,85118.57664,percent of total billed charges,
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,S5000,HCPCS,259,RC,63323-0877-15,NDC,outpatient,1,UN,686.24,480.368,AETNA [1000108],AETNA [100010801],,,76.8,,527.03,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAPS,RX-28278,CDM,S5000,HCPCS,259,RC,00904-7107-61,NDC,outpatient,1,UN,10.27,7.189,AETNA [1000108],AETNA [100010801],,,76.8,,7.89,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE TARTRATE 3 MG ORAL CAPS,RX-28279,CDM,S5000,HCPCS,259,RC,55111-0353-60,NDC,outpatient,1,UN,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,
INSULIN GLARGINE 100 UNIT/ML SC SOLN,RX-28282,CDM,S5000,HCPCS,259,RC,00088-2220-33,NDC,outpatient,10,ML,252.19,176.533,AETNA [1000108],AETNA [100010801],,,76.8,,193.68,0.222255,85118.57664,percent of total billed charges,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-25,NDC,outpatient,1,UN,13.08,9.156,AETNA [1000108],AETNA [100010801],,,76.8,,10.05,0.222255,85118.57664,percent of total billed charges,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-95,NDC,outpatient,1,UN,13.08,9.156,AETNA [1000108],AETNA [100010801],,,76.8,,10.05,0.222255,85118.57664,percent of total billed charges,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-23,NDC,outpatient,1,UN,2,1.4,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-62,NDC,outpatient,1,UN,2,1.4,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-16,NDC,outpatient,1,UN,65.95,46.165,AETNA [1000108],AETNA [100010801],,,76.8,,50.65,0.222255,85118.57664,percent of total billed charges,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-99,NDC,outpatient,1,UN,65.95,46.165,AETNA [1000108],AETNA [100010801],,,76.8,,50.65,0.222255,85118.57664,percent of total billed charges,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-16,NDC,outpatient,1,UN,65.26,45.682,AETNA [1000108],AETNA [100010801],,,76.8,,50.12,0.222255,85118.57664,percent of total billed charges,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-99,NDC,outpatient,1,UN,65.26,45.682,AETNA [1000108],AETNA [100010801],,,76.8,,50.12,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-11,NDC,outpatient,1,UN,5.37,3.759,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-01,NDC,outpatient,1,UN,5.37,3.759,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,50458-0585-01,NDC,outpatient,1,UN,53.04,37.128,AETNA [1000108],AETNA [100010801],,,76.8,,40.73,0.222255,85118.57664,percent of total billed charges,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,13811-0706-10,NDC,outpatient,1,UN,3.22,2.254,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00487-9601-01,NDC,outpatient,2,ML,17.76,12.432,AETNA [1000108],AETNA [100010801],,,76.8,,13.64,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00186-1988-04,NDC,outpatient,2,ML,35.8,25.06,AETNA [1000108],AETNA [100010801],,,76.8,,27.49,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-53,NDC,outpatient,2,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-73,NDC,outpatient,2,ML,39.45,27.615,AETNA [1000108],AETNA [100010801],,,76.8,,30.3,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00487-9701-01,NDC,outpatient,2,ML,14.93,10.451,AETNA [1000108],AETNA [100010801],,,76.8,,11.47,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-05,NDC,outpatient,2,ML,5.21,3.647,AETNA [1000108],AETNA [100010801],,,76.8,,4,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-32,NDC,outpatient,2,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-30,NDC,outpatient,2,ML,5.21,3.647,AETNA [1000108],AETNA [100010801],,,76.8,,4,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-45,NDC,outpatient,2,ML,39.45,27.615,AETNA [1000108],AETNA [100010801],,,76.8,,30.3,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,47335-0632-49,NDC,outpatient,1,ML,6.14,4.298,AETNA [1000108],AETNA [100010801],,,76.8,,4.72,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-86,NDC,outpatient,2,ML,8.61,6.027,AETNA [1000108],AETNA [100010801],,,76.8,,6.61,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-87,NDC,outpatient,2,ML,8.61,6.027,AETNA [1000108],AETNA [100010801],,,76.8,,6.61,0.222255,85118.57664,percent of total billed charges,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-21,NDC,outpatient,28.35,GR,7.2,5.04,AETNA [1000108],AETNA [100010801],,,76.8,,5.53,0.222255,85118.57664,percent of total billed charges,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,08080-4302-01,NDC,outpatient,30,ML,5.88,4.116,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,0.222255,85118.57664,percent of total billed charges,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,53329-0993-04,NDC,outpatient,113,GR,5.26,3.682,AETNA [1000108],AETNA [100010801],,,76.8,,4.04,0.222255,85118.57664,percent of total billed charges,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-16,NDC,outpatient,453.6,GR,58.59,41.013,AETNA [1000108],AETNA [100010801],,,76.8,,45,0.222255,85118.57664,percent of total billed charges,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2311-00,NDC,outpatient,52.5,GR,7.25,5.075,AETNA [1000108],AETNA [100010801],,,76.8,,5.57,0.222255,85118.57664,percent of total billed charges,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,38779-3068-00,NDC,outpatient,30,GR,75.03,52.521,AETNA [1000108],AETNA [100010801],,,76.8,,57.62,0.222255,85118.57664,percent of total billed charges,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2335-00,NDC,outpatient,390,GR,19.1,13.37,AETNA [1000108],AETNA [100010801],,,76.8,,14.67,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,24208-0635-62,NDC,outpatient,10,ML,221.08,154.756,AETNA [1000108],AETNA [100010801],,,76.8,,169.79,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,61314-0645-11,NDC,outpatient,10,ML,217.88,152.516,AETNA [1000108],AETNA [100010801],,,76.8,,167.33,0.222255,85118.57664,percent of total billed charges,
GLYCERIN LIQD,RX-28815,CDM,S5000,HCPCS,259,RC,00395-1031-96,NDC,outpatient,177,ML,23.63,16.541,AETNA [1000108],AETNA [100010801],,,76.8,,18.15,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP,RX-28836,CDM,S5000,HCPCS,259,RC,00121-0431-30,NDC,outpatient,30,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-65,NDC,outpatient,1,UN,1.84,1.288,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-19,NDC,outpatient,1,UN,1.84,1.288,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-15,NDC,outpatient,1,UN,46.19,32.333,AETNA [1000108],AETNA [100010801],,,76.8,,35.47,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-61,NDC,outpatient,1,UN,46.19,32.333,AETNA [1000108],AETNA [100010801],,,76.8,,35.47,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,RX-28844,CDM,S5000,HCPCS,259,RC,00172-7313-20,NDC,outpatient,50,ML,396.5,277.55,AETNA [1000108],AETNA [100010801],,,76.8,,304.51,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN 2 % EX SOLN,RX-2887,CDM,S5000,HCPCS,259,RC,45802-0038-46,NDC,outpatient,60,ML,71.56,50.092,AETNA [1000108],AETNA [100010801],,,76.8,,54.96,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-50,NDC,outpatient,1,GR,31.37,21.959,AETNA [1000108],AETNA [100010801],,,76.8,,24.09,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-11,NDC,outpatient,1,GR,31.37,21.959,AETNA [1000108],AETNA [100010801],,,76.8,,24.09,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,48102-0057-11,NDC,outpatient,1,GR,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,24208-0910-19,NDC,outpatient,1,GR,31.03,21.721,AETNA [1000108],AETNA [100010801],,,76.8,,23.83,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-01,NDC,outpatient,1,UN,4.25,2.975,AETNA [1000108],AETNA [100010801],,,76.8,,3.26,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-59,NDC,outpatient,1,UN,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-11,NDC,outpatient,1,UN,4.25,2.975,AETNA [1000108],AETNA [100010801],,,76.8,,3.26,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-23,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-62,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-61,NDC,outpatient,1,UN,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,24338-0122-03,NDC,outpatient,1,UN,24.57,17.199,AETNA [1000108],AETNA [100010801],,,76.8,,18.87,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,13668-0586-30,NDC,outpatient,1,UN,21.71,15.197,AETNA [1000108],AETNA [100010801],,,76.8,,16.67,0.222255,85118.57664,percent of total billed charges,
NA HYALUR & NA CHOND-NA HYALUR 0.4-0.35 ML IO KIT,RX-28916,CDM,S5000,HCPCS,250,RC,08065-1831-35,NDC,outpatient,0.75,ML,867.31,607.117,AETNA [1000108],AETNA [100010801],,,76.8,,666.09,0.222255,85118.57664,percent of total billed charges,
LEVOFLOXACIN 750 MG ORAL TABS,RX-28964,CDM,S5000,HCPCS,259,RC,00904-6353-61,NDC,outpatient,1,UN,2.17,1.519,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,24338-0134-02,NDC,outpatient,100,ML,1005.7,703.99,AETNA [1000108],AETNA [100010801],,,76.8,,772.38,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,99999-0002-77,NDC,outpatient,5,ML,50.87,35.609,AETNA [1000108],AETNA [100010801],,,76.8,,39.07,0.222255,85118.57664,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,75834-0295-01,NDC,outpatient,100,ML,494.4,346.08,AETNA [1000108],AETNA [100010801],,,76.8,,379.7,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,51224-0007-50,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,70010-0491-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALENDRONATE SODIUM 70 MG ORAL TABS,RX-29048,CDM,S5000,HCPCS,259,RC,16714-0633-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
ALENDRONATE SODIUM 35 MG ORAL TABS,RX-29072,CDM,S5000,HCPCS,259,RC,16714-0632-01,NDC,outpatient,1,UN,5.43,3.801,AETNA [1000108],AETNA [100010801],,,76.8,,4.17,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-40,NDC,outpatient,6,ML,15.62,10.934,AETNA [1000108],AETNA [100010801],,,76.8,,12,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-06,NDC,outpatient,6,ML,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-90,NDC,outpatient,473,ML,168.39,117.873,AETNA [1000108],AETNA [100010801],,,76.8,,129.32,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-07,NDC,outpatient,470,ML,154.78,108.346,AETNA [1000108],AETNA [100010801],,,76.8,,118.87,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,99999-0003-42,NDC,outpatient,6,ML,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-06,NDC,outpatient,6,ML,15.62,10.934,AETNA [1000108],AETNA [100010801],,,76.8,,12,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-16,NDC,outpatient,470,ML,144.32,101.024,AETNA [1000108],AETNA [100010801],,,76.8,,110.84,0.222255,85118.57664,percent of total billed charges,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-06,NDC,outpatient,6,ML,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-30,NDC,outpatient,1,UN,1.44,1.008,AETNA [1000108],AETNA [100010801],,,76.8,,1.11,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-01,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-11,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,68682-0993-98,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,00904-7218-61,NDC,outpatient,1,UN,1.28,0.896,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-11,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,62037-0598-90,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,00904-7219-61,NDC,outpatient,1,UN,1.59,1.113,AETNA [1000108],AETNA [100010801],,,76.8,,1.22,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-11,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-01,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-01,NDC,outpatient,1,UN,6.23,4.361,AETNA [1000108],AETNA [100010801],,,76.8,,4.78,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,24979-0029-07,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-11,NDC,outpatient,1,UN,6.23,4.361,AETNA [1000108],AETNA [100010801],,,76.8,,4.78,0.222255,85118.57664,percent of total billed charges,
DOCOSANOL 10 % EX CREA,RX-29287,CDM,S5000,HCPCS,259,RC,00135-0300-01,NDC,outpatient,2,GR,72.76,50.932,AETNA [1000108],AETNA [100010801],,,76.8,,55.88,0.222255,85118.57664,percent of total billed charges,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,00054-0079-28,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-11,NDC,outpatient,1,UN,5.8,4.06,AETNA [1000108],AETNA [100010801],,,76.8,,4.45,0.222255,85118.57664,percent of total billed charges,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-13,NDC,outpatient,1,UN,5.8,4.06,AETNA [1000108],AETNA [100010801],,,76.8,,4.45,0.222255,85118.57664,percent of total billed charges,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,60505-2575-07,NDC,outpatient,1,UN,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,65649-0101-02,NDC,outpatient,1,UN,26.86,18.802,AETNA [1000108],AETNA [100010801],,,76.8,,20.63,0.222255,85118.57664,percent of total billed charges,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,72789-0149-69,NDC,outpatient,1,UN,1.89,1.323,AETNA [1000108],AETNA [100010801],,,76.8,,1.45,0.222255,85118.57664,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,16714-0496-01,NDC,outpatient,15,GR,55.61,38.927,AETNA [1000108],AETNA [100010801],,,76.8,,42.71,0.222255,85118.57664,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,00168-0258-15,NDC,outpatient,15,GR,71.29,49.903,AETNA [1000108],AETNA [100010801],,,76.8,,54.75,0.222255,85118.57664,percent of total billed charges,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-21,NDC,outpatient,1,UN,7.98,5.586,AETNA [1000108],AETNA [100010801],,,76.8,,6.13,0.222255,85118.57664,percent of total billed charges,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-11,NDC,outpatient,1,UN,7.98,5.586,AETNA [1000108],AETNA [100010801],,,76.8,,6.13,0.222255,85118.57664,percent of total billed charges,
MIRTAZAPINE 15 MG ORAL TBDP,RX-29531,CDM,S5000,HCPCS,259,RC,65862-0021-06,NDC,outpatient,1,UN,1.96,1.372,AETNA [1000108],AETNA [100010801],,,76.8,,1.51,0.222255,85118.57664,percent of total billed charges,
ZIPRASIDONE HCL 20 MG ORAL CAPS,RX-29778,CDM,S5000,HCPCS,259,RC,00904-6269-08,NDC,outpatient,1,UN,11.99,8.393,AETNA [1000108],AETNA [100010801],,,76.8,,9.21,0.222255,85118.57664,percent of total billed charges,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-11,NDC,outpatient,1,UN,7.96,5.572,AETNA [1000108],AETNA [100010801],,,76.8,,6.11,0.222255,85118.57664,percent of total billed charges,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-09,NDC,outpatient,1,UN,7.81,5.467,AETNA [1000108],AETNA [100010801],,,76.8,,6,0.222255,85118.57664,percent of total billed charges,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-11,NDC,outpatient,1,UN,7.81,5.467,AETNA [1000108],AETNA [100010801],,,76.8,,6,0.222255,85118.57664,percent of total billed charges,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-12,NDC,outpatient,1,UN,7.96,5.572,AETNA [1000108],AETNA [100010801],,,76.8,,6.11,0.222255,85118.57664,percent of total billed charges,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,00781-2168-60,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-09,NDC,outpatient,1,UN,7.81,5.467,AETNA [1000108],AETNA [100010801],,,76.8,,6,0.222255,85118.57664,percent of total billed charges,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-11,NDC,outpatient,1,UN,7.81,5.467,AETNA [1000108],AETNA [100010801],,,76.8,,6,0.222255,85118.57664,percent of total billed charges,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-11,NDC,outpatient,1,UN,14.03,9.821,AETNA [1000108],AETNA [100010801],,,76.8,,10.78,0.222255,85118.57664,percent of total billed charges,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-21,NDC,outpatient,1,UN,14.03,9.821,AETNA [1000108],AETNA [100010801],,,76.8,,10.78,0.222255,85118.57664,percent of total billed charges,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,70436-0004-06,NDC,outpatient,1,UN,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-01,NDC,outpatient,1,UN,2.11,1.477,AETNA [1000108],AETNA [100010801],,,76.8,,1.62,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,50742-0615-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,45963-0709-11,NDC,outpatient,1,UN,1.28,0.896,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-06,NDC,outpatient,1,UN,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-61,NDC,outpatient,1,UN,2.19,1.533,AETNA [1000108],AETNA [100010801],,,76.8,,1.68,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-20,NDC,outpatient,1,UN,2.11,1.477,AETNA [1000108],AETNA [100010801],,,76.8,,1.62,0.222255,85118.57664,percent of total billed charges,
EYE STREAM OP SOLN,RX-2999,CDM,S5000,HCPCS,259,RC,00065-0530-01,NDC,outpatient,30,ML,81.97,57.379,AETNA [1000108],AETNA [100010801],,,76.8,,62.95,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,00904-6323-61,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-20,NDC,outpatient,1,UN,1.9,1.33,AETNA [1000108],AETNA [100010801],,,76.8,,1.46,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-01,NDC,outpatient,1,UN,1.9,1.33,AETNA [1000108],AETNA [100010801],,,76.8,,1.46,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,68382-0565-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,50742-0616-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-11,NDC,outpatient,1,UN,2.35,1.645,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-15,NDC,outpatient,1,UN,2.35,1.645,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-03,NDC,outpatient,1,UN,5.81,4.067,AETNA [1000108],AETNA [100010801],,,76.8,,4.46,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-01,NDC,outpatient,1,UN,5.81,4.067,AETNA [1000108],AETNA [100010801],,,76.8,,4.46,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-01,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,00904-6324-61,NDC,outpatient,1,UN,2.66,1.862,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-11,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,63739-0357-33,NDC,outpatient,1,UN,93.6,65.52,AETNA [1000108],AETNA [100010801],,,76.8,,71.88,0.222255,85118.57664,percent of total billed charges,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-25,NDC,outpatient,1,UN,121.31,84.917,AETNA [1000108],AETNA [100010801],,,76.8,,93.17,0.222255,85118.57664,percent of total billed charges,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-95,NDC,outpatient,1,UN,121.31,84.917,AETNA [1000108],AETNA [100010801],,,76.8,,93.17,0.222255,85118.57664,percent of total billed charges,
CITALOPRAM HYDROBROMIDE 10 MG ORAL TABS,RX-30264,CDM,S5000,HCPCS,259,RC,00904-6084-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-62,NDC,outpatient,5,ML,23.66,16.562,AETNA [1000108],AETNA [100010801],,,76.8,,18.17,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,00078-0357-52,NDC,outpatient,5,ML,39.3,27.51,AETNA [1000108],AETNA [100010801],,,76.8,,30.18,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,99999-0002-25,NDC,outpatient,5,ML,33.09,23.163,AETNA [1000108],AETNA [100010801],,,76.8,,25.41,0.222255,85118.57664,percent of total billed charges,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-59,NDC,outpatient,5,ML,23.66,16.562,AETNA [1000108],AETNA [100010801],,,76.8,,18.17,0.222255,85118.57664,percent of total billed charges,
MELATONIN 5 MG SL SUBL,RX-30511,CDM,S5000,HCPCS,259,RC,54629-0615-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7591-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7590-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,20555-0021-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,16714-0576-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,00904-7041-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-01,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-20,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,55111-0729-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-20,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,00904-6572-61,NDC,outpatient,1,UN,1.71,1.197,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-01,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,00143-9853-75,NDC,outpatient,75,ML,63.42,44.394,AETNA [1000108],AETNA [100010801],,,76.8,,48.71,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,99999-0002-82,NDC,outpatient,5,ML,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,0.222255,85118.57664,percent of total billed charges,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,33342-0064-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-01,NDC,outpatient,1,UN,4.62,3.234,AETNA [1000108],AETNA [100010801],,,76.8,,3.55,0.222255,85118.57664,percent of total billed charges,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,31722-0153-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-11,NDC,outpatient,1,UN,4.62,3.234,AETNA [1000108],AETNA [100010801],,,76.8,,3.55,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,65162-0778-10,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,00574-9855-10,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,00487-0301-01,NDC,outpatient,3,ML,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,76204-0010-55,NDC,outpatient,3,ML,1.98,1.386,AETNA [1000108],AETNA [100010801],,,76.8,,1.52,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-01,NDC,outpatient,3,ML,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-25,NDC,outpatient,3,ML,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,00228-3059-11,NDC,outpatient,1,UN,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,64850-0511-01,NDC,outpatient,1,UN,2,1.4,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,70010-0030-01,NDC,outpatient,1,UN,3.45,2.415,AETNA [1000108],AETNA [100010801],,,76.8,,2.65,0.222255,85118.57664,percent of total billed charges,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,54295-0312-18,NDC,outpatient,226.8,GR,419.86,293.902,AETNA [1000108],AETNA [100010801],,,76.8,,322.45,0.222255,85118.57664,percent of total billed charges,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,81542-0201-08,NDC,outpatient,226.8,GR,454.17,317.919,AETNA [1000108],AETNA [100010801],,,76.8,,348.8,0.222255,85118.57664,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TABS,RX-31684,CDM,S5000,HCPCS,259,RC,61958-0401-01,NDC,outpatient,1,UN,180.36,126.252,AETNA [1000108],AETNA [100010801],,,76.8,,138.52,0.222255,85118.57664,percent of total billed charges,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,00093-0262-15,NDC,outpatient,15,GR,162.14,113.498,AETNA [1000108],AETNA [100010801],,,76.8,,124.52,0.222255,85118.57664,percent of total billed charges,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,51672-1386-01,NDC,outpatient,15,GR,35.32,24.724,AETNA [1000108],AETNA [100010801],,,76.8,,27.13,0.222255,85118.57664,percent of total billed charges,
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,S5000,HCPCS,259,RC,51672-1264-01,NDC,outpatient,15,GR,55.01,38.507,AETNA [1000108],AETNA [100010801],,,76.8,,42.25,0.222255,85118.57664,percent of total billed charges,
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,S5000,HCPCS,259,RC,51672-1273-02,NDC,outpatient,20,ML,137.87,96.509,AETNA [1000108],AETNA [100010801],,,76.8,,105.88,0.222255,85118.57664,percent of total billed charges,
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,S5000,HCPCS,259,RC,60758-0880-05,NDC,outpatient,5,ML,308.83,216.181,AETNA [1000108],AETNA [100010801],,,76.8,,237.18,0.222255,85118.57664,percent of total billed charges,
FLUPHENAZINE HCL 1 MG ORAL TABS,RX-3218,CDM,S5000,HCPCS,259,RC,00527-1788-01,NDC,outpatient,1,UN,6.6,4.62,AETNA [1000108],AETNA [100010801],,,76.8,,5.07,0.222255,85118.57664,percent of total billed charges,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,00527-1789-01,NDC,outpatient,1,UN,10.2,7.14,AETNA [1000108],AETNA [100010801],,,76.8,,7.83,0.222255,85118.57664,percent of total billed charges,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,70954-0274-10,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,00527-1790-01,NDC,outpatient,1,UN,13.8,9.66,AETNA [1000108],AETNA [100010801],,,76.8,,10.6,0.222255,85118.57664,percent of total billed charges,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,69238-1680-01,NDC,outpatient,1,UN,6.45,4.515,AETNA [1000108],AETNA [100010801],,,76.8,,4.95,0.222255,85118.57664,percent of total billed charges,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,39822-1100-01,NDC,outpatient,0.2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,63323-0184-10,NDC,outpatient,0.2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,00904-7224-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,00781-1061-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,65862-0676-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALPRAZOLAM 0.5 MG ORAL TABS,RX-325,CDM,S5000,HCPCS,259,RC,00781-1077-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PAROXETINE HCL ER 12.5 MG ORAL TB24,RX-32631,CDM,S5000,HCPCS,259,RC,62175-0470-32,NDC,outpatient,1,UN,4.97,3.479,AETNA [1000108],AETNA [100010801],,,76.8,,3.82,0.222255,85118.57664,percent of total billed charges,
METHYLPHENIDATE HCL ER (OSM) 27 MG ORAL TBCR,RX-32654,CDM,S5000,HCPCS,259,RC,13811-0707-10,NDC,outpatient,1,UN,3.33,2.331,AETNA [1000108],AETNA [100010801],,,76.8,,2.56,0.222255,85118.57664,percent of total billed charges,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,00713-0861-30,NDC,outpatient,1,UN,39.98,27.986,AETNA [1000108],AETNA [100010801],,,76.8,,30.7,0.222255,85118.57664,percent of total billed charges,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,33342-0179-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,68462-0437-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RISEDRONATE SODIUM 35 MG ORAL TABS,RX-32895,CDM,S5000,HCPCS,259,RC,33342-0109-50,NDC,outpatient,1,UN,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-59,NDC,outpatient,4,ML,7.04,4.928,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-62,NDC,outpatient,4,ML,7.04,4.928,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-59,NDC,outpatient,5,ML,7.04,4.928,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-62,NDC,outpatient,5,ML,7.04,4.928,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00054-8297-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00904-7177-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,00054-8301-25,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMPHETAMINE-DEXTROAMPHET ER 5 MG ORAL CP24,RX-33005,CDM,S5000,HCPCS,259,RC,54092-0381-01,NDC,outpatient,1,UN,29.29,20.503,AETNA [1000108],AETNA [100010801],,,76.8,,22.49,0.222255,85118.57664,percent of total billed charges,
VORICONAZOLE 200 MG ORAL TABS,RX-33009,CDM,S5000,HCPCS,259,RC,00904-7024-04,NDC,outpatient,1,UN,43.81,30.667,AETNA [1000108],AETNA [100010801],,,76.8,,33.65,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TABS,RX-33227,CDM,S5000,HCPCS,259,RC,00781-1831-01,NDC,outpatient,1,UN,1.59,1.113,AETNA [1000108],AETNA [100010801],,,76.8,,1.22,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,42571-0162-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-01,NDC,outpatient,1,UN,2.34,1.638,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-20,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,00143-9249-20,NDC,outpatient,1,UN,5.26,3.682,AETNA [1000108],AETNA [100010801],,,76.8,,4.04,0.222255,85118.57664,percent of total billed charges,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-01,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,00904-6426-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-11,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,31722-0151-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-21,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-11,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-11,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-01,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
METAXALONE 800 MG ORAL TABS,RX-33963,CDM,S5000,HCPCS,259,RC,00527-1435-01,NDC,outpatient,1,UN,2.54,1.778,AETNA [1000108],AETNA [100010801],,,76.8,,1.95,0.222255,85118.57664,percent of total billed charges,
DUTASTERIDE 0.5 MG ORAL CAPS,RX-34089,CDM,S5000,HCPCS,259,RC,42806-0549-09,NDC,outpatient,1,UN,1.7,1.19,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,51660-0200-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-21,NDC,outpatient,1,UN,18.75,13.125,AETNA [1000108],AETNA [100010801],,,76.8,,14.4,0.222255,85118.57664,percent of total billed charges,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,00904-7103-04,NDC,outpatient,1,UN,18.36,12.852,AETNA [1000108],AETNA [100010801],,,76.8,,14.1,0.222255,85118.57664,percent of total billed charges,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-11,NDC,outpatient,1,UN,18.75,13.125,AETNA [1000108],AETNA [100010801],,,76.8,,14.4,0.222255,85118.57664,percent of total billed charges,
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,S5000,HCPCS,259,RC,45802-0056-35,NDC,outpatient,15,GR,170.02,119.014,AETNA [1000108],AETNA [100010801],,,76.8,,130.58,0.222255,85118.57664,percent of total billed charges,
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,S5000,HCPCS,259,RC,45802-0046-35,NDC,outpatient,15,GR,132.44,92.708,AETNA [1000108],AETNA [100010801],,,76.8,,101.71,0.222255,85118.57664,percent of total billed charges,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,24208-0580-60,NDC,outpatient,5,ML,23.41,16.387,AETNA [1000108],AETNA [100010801],,,76.8,,17.98,0.222255,85118.57664,percent of total billed charges,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,61314-0633-05,NDC,outpatient,5,ML,21.99,15.393,AETNA [1000108],AETNA [100010801],,,76.8,,16.89,0.222255,85118.57664,percent of total billed charges,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-01,NDC,outpatient,1,UN,22.5,15.75,AETNA [1000108],AETNA [100010801],,,76.8,,17.28,0.222255,85118.57664,percent of total billed charges,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-11,NDC,outpatient,1,UN,22.5,15.75,AETNA [1000108],AETNA [100010801],,,76.8,,17.28,0.222255,85118.57664,percent of total billed charges,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,27241-0054-03,NDC,outpatient,1,UN,2.88,2.016,AETNA [1000108],AETNA [100010801],,,76.8,,2.21,0.222255,85118.57664,percent of total billed charges,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-11,NDC,outpatient,1,UN,27.24,19.068,AETNA [1000108],AETNA [100010801],,,76.8,,20.92,0.222255,85118.57664,percent of total billed charges,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-21,NDC,outpatient,1,UN,27.24,19.068,AETNA [1000108],AETNA [100010801],,,76.8,,20.92,0.222255,85118.57664,percent of total billed charges,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,63739-0078-33,NDC,outpatient,1,UN,22.38,15.666,AETNA [1000108],AETNA [100010801],,,76.8,,17.19,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-11,NDC,outpatient,1,UN,2.75,1.925,AETNA [1000108],AETNA [100010801],,,76.8,,2.11,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-01,NDC,outpatient,1,UN,2.75,1.925,AETNA [1000108],AETNA [100010801],,,76.8,,2.11,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,31722-0714-30,NDC,outpatient,1,UN,8.16,5.712,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,55111-0519-30,NDC,outpatient,1,UN,7.25,5.075,AETNA [1000108],AETNA [100010801],,,76.8,,5.57,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,68462-0265-30,NDC,outpatient,1,UN,4.5,3.15,AETNA [1000108],AETNA [100010801],,,76.8,,3.46,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,35573-0415-30,NDC,outpatient,1,UN,14,9.8,AETNA [1000108],AETNA [100010801],,,76.8,,10.75,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,16714-0757-01,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,64980-0375-03,NDC,outpatient,1,UN,7.25,5.075,AETNA [1000108],AETNA [100010801],,,76.8,,5.57,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,00093-3545-56,NDC,outpatient,1,UN,17.9,12.53,AETNA [1000108],AETNA [100010801],,,76.8,,13.75,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-95,NDC,outpatient,1,UN,14.68,10.276,AETNA [1000108],AETNA [100010801],,,76.8,,11.27,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,68462-0268-30,NDC,outpatient,1,UN,2.91,2.037,AETNA [1000108],AETNA [100010801],,,76.8,,2.23,0.222255,85118.57664,percent of total billed charges,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-25,NDC,outpatient,1,UN,14.68,10.276,AETNA [1000108],AETNA [100010801],,,76.8,,11.27,0.222255,85118.57664,percent of total billed charges,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-23,NDC,outpatient,1,UN,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-62,NDC,outpatient,1,UN,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-11,NDC,outpatient,1,UN,6.96,4.872,AETNA [1000108],AETNA [100010801],,,76.8,,5.35,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-21,NDC,outpatient,1,UN,6.96,4.872,AETNA [1000108],AETNA [100010801],,,76.8,,5.35,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-21,NDC,outpatient,1,UN,11.98,8.386,AETNA [1000108],AETNA [100010801],,,76.8,,9.2,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,42858-0502-03,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-11,NDC,outpatient,1,UN,11.98,8.386,AETNA [1000108],AETNA [100010801],,,76.8,,9.2,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,00054-0188-13,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,65162-0416-03,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-15,NDC,outpatient,1,UN,14.96,10.472,AETNA [1000108],AETNA [100010801],,,76.8,,11.49,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-11,NDC,outpatient,1,UN,14.96,10.472,AETNA [1000108],AETNA [100010801],,,76.8,,11.49,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,42858-0602-03,NDC,outpatient,1,UN,27,18.9,AETNA [1000108],AETNA [100010801],,,76.8,,20.74,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,24208-0631-10,NDC,outpatient,10,ML,205.06,143.542,AETNA [1000108],AETNA [100010801],,,76.8,,157.49,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,61314-0646-10,NDC,outpatient,10,ML,188.28,131.796,AETNA [1000108],AETNA [100010801],,,76.8,,144.6,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,00904-6779-61,NDC,outpatient,1,UN,3.97,2.779,AETNA [1000108],AETNA [100010801],,,76.8,,3.05,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-01,NDC,outpatient,1,UN,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-11,NDC,outpatient,1,UN,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-11,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,00904-6780-61,NDC,outpatient,1,UN,3.57,2.499,AETNA [1000108],AETNA [100010801],,,76.8,,2.74,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-15,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-01,NDC,outpatient,1,UN,5.36,3.752,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-11,NDC,outpatient,1,UN,5.36,3.752,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,16714-0990-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,S5000,HCPCS,259,RC,00023-9163-30,NDC,outpatient,1,UN,44.22,30.954,AETNA [1000108],AETNA [100010801],,,76.8,,33.96,0.222255,85118.57664,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,00536-0091-85,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,99999-0002-48,NDC,outpatient,30,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GRISEOFULVIN ULTRAMICROSIZE 250 MG ORAL TABS,RX-3536,CDM,S5000,HCPCS,259,RC,00115-1725-01,NDC,outpatient,1,UN,20.98,14.686,AETNA [1000108],AETNA [100010801],,,76.8,,16.11,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-01,NDC,outpatient,1,UN,349.43,244.601,AETNA [1000108],AETNA [100010801],,,76.8,,268.36,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-08,NDC,outpatient,1,UN,349.43,244.601,AETNA [1000108],AETNA [100010801],,,76.8,,268.36,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-08,NDC,outpatient,1,UN,10.21,7.147,AETNA [1000108],AETNA [100010801],,,76.8,,7.84,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-01,NDC,outpatient,1,UN,10.21,7.147,AETNA [1000108],AETNA [100010801],,,76.8,,7.84,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-55,NDC,outpatient,1,UN,2.41,1.687,AETNA [1000108],AETNA [100010801],,,76.8,,1.85,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-52,NDC,outpatient,1,UN,2.41,1.687,AETNA [1000108],AETNA [100010801],,,76.8,,1.85,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-52,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-55,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,00832-1410-03,NDC,outpatient,3,ML,113.88,79.716,AETNA [1000108],AETNA [100010801],,,76.8,,87.46,0.222255,85118.57664,percent of total billed charges,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,72266-0158-01,NDC,outpatient,3,ML,45.03,31.521,AETNA [1000108],AETNA [100010801],,,76.8,,34.58,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,62756-0143-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,67877-0414-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,70010-0492-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00832-1530-11,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00378-0214-01,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-20,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-01,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,54838-0501-15,NDC,outpatient,0.5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,99999-0003-09,NDC,outpatient,0.5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,63739-0972-10,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-89,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-01,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-89,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-01,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00832-5325-11,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,
ATAZANAVIR SULFATE 150 MG ORAL CAPS,RX-36149,CDM,S5000,HCPCS,259,RC,42385-0920-60,NDC,outpatient,1,UN,11.33,7.931,AETNA [1000108],AETNA [100010801],,,76.8,,8.7,0.222255,85118.57664,percent of total billed charges,
ATAZANAVIR SULFATE 200 MG ORAL CAPS,RX-36150,CDM,S5000,HCPCS,259,RC,65862-0712-60,NDC,outpatient,1,UN,13.22,9.254,AETNA [1000108],AETNA [100010801],,,76.8,,10.15,0.222255,85118.57664,percent of total billed charges,
PREMASOL 10 % IV SOLN,RX-36160,CDM,S5000,HCPCS,250,RC,00338-1130-03,NDC,outpatient,500,ML,98.33,68.831,AETNA [1000108],AETNA [100010801],,,76.8,,75.52,0.222255,85118.57664,percent of total billed charges,
EMTRICITABINE 200 MG ORAL CAPS,RX-36252,CDM,S5000,HCPCS,259,RC,61958-0601-01,NDC,outpatient,1,UN,77.2,54.04,AETNA [1000108],AETNA [100010801],,,76.8,,59.29,0.222255,85118.57664,percent of total billed charges,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-15,NDC,outpatient,1,UN,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.222255,85118.57664,percent of total billed charges,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-11,NDC,outpatient,1,UN,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.222255,85118.57664,percent of total billed charges,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-11,NDC,outpatient,1,UN,15.64,10.948,AETNA [1000108],AETNA [100010801],,,76.8,,12.01,0.222255,85118.57664,percent of total billed charges,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-01,NDC,outpatient,1,UN,15.64,10.948,AETNA [1000108],AETNA [100010801],,,76.8,,12.01,0.222255,85118.57664,percent of total billed charges,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,16714-0628-01,NDC,outpatient,7.5,ML,422.83,295.981,AETNA [1000108],AETNA [100010801],,,76.8,,324.73,0.222255,85118.57664,percent of total billed charges,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,43598-0326-75,NDC,outpatient,7.5,ML,438.69,307.083,AETNA [1000108],AETNA [100010801],,,76.8,,336.91,0.222255,85118.57664,percent of total billed charges,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,62756-0427-90,NDC,outpatient,7.5,ML,336.96,235.872,AETNA [1000108],AETNA [100010801],,,76.8,,258.79,0.222255,85118.57664,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-05,NDC,outpatient,5,ML,9.93,6.951,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,0.222255,85118.57664,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-67,NDC,outpatient,5,ML,12.02,8.414,AETNA [1000108],AETNA [100010801],,,76.8,,9.23,0.222255,85118.57664,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-40,NDC,outpatient,5,ML,9.93,6.951,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,0.222255,85118.57664,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-40,NDC,outpatient,5,ML,12.02,8.414,AETNA [1000108],AETNA [100010801],,,76.8,,9.23,0.222255,85118.57664,percent of total billed charges,
ROSUVASTATIN CALCIUM 5 MG ORAL TABS,RX-36612,CDM,S5000,HCPCS,259,RC,00904-6778-61,NDC,outpatient,1,UN,2.9,2.03,AETNA [1000108],AETNA [100010801],,,76.8,,2.23,0.222255,85118.57664,percent of total billed charges,
KETOROLAC TROMETHAMINE 0.4 % OP SOLN,RX-36631,CDM,S5000,HCPCS,259,RC,60758-0773-05,NDC,outpatient,5,ML,248.94,174.258,AETNA [1000108],AETNA [100010801],,,76.8,,191.19,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-04,NDC,outpatient,1,UN,5.27,3.689,AETNA [1000108],AETNA [100010801],,,76.8,,4.05,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-61,NDC,outpatient,1,UN,6.35,4.445,AETNA [1000108],AETNA [100010801],,,76.8,,4.88,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,16729-0443-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-10,NDC,outpatient,10,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,99999-0001-96,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-00,NDC,outpatient,10,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-10,NDC,outpatient,10,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.222255,85118.57664,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-01,NDC,outpatient,10,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,29033-0001-01,NDC,outpatient,1,UN,5.44,3.808,AETNA [1000108],AETNA [100010801],,,76.8,,4.18,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,42858-0701-01,NDC,outpatient,1,UN,3.89,2.723,AETNA [1000108],AETNA [100010801],,,76.8,,2.99,0.222255,85118.57664,percent of total billed charges,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,49348-0991-36,NDC,outpatient,177,ML,7.88,5.516,AETNA [1000108],AETNA [100010801],,,76.8,,6.05,0.222255,85118.57664,percent of total billed charges,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,00904-6305-21,NDC,outpatient,177,ML,7.09,4.963,AETNA [1000108],AETNA [100010801],,,76.8,,5.45,0.222255,85118.57664,percent of total billed charges,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,78112-0011-03,NDC,outpatient,177,ML,17.33,12.131,AETNA [1000108],AETNA [100010801],,,76.8,,13.31,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,29300-0155-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,57237-0114-90,NDC,outpatient,1,UN,2,1.4,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,51991-0877-33,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,59762-1710-02,NDC,outpatient,1,UN,5.59,3.913,AETNA [1000108],AETNA [100010801],,,76.8,,4.29,0.222255,85118.57664,percent of total billed charges,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-11,NDC,outpatient,1,UN,18.55,12.985,AETNA [1000108],AETNA [100010801],,,76.8,,14.25,0.222255,85118.57664,percent of total billed charges,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-21,NDC,outpatient,1,UN,18.55,12.985,AETNA [1000108],AETNA [100010801],,,76.8,,14.25,0.222255,85118.57664,percent of total billed charges,
ZONISAMIDE 25 MG ORAL CAPS,RX-36987,CDM,S5000,HCPCS,259,RC,68462-0128-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-01,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,23155-0833-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,31722-0520-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,63739-0327-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-20,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,00536-3445-08,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,57896-0621-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-44,NDC,outpatient,1,UN,1.42,0.994,AETNA [1000108],AETNA [100010801],,,76.8,,1.09,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00904-6505-61,NDC,outpatient,1,UN,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-45,NDC,outpatient,1,UN,1.42,0.994,AETNA [1000108],AETNA [100010801],,,76.8,,1.09,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00832-1112-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-11,NDC,outpatient,1,UN,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-57,NDC,outpatient,1,UN,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,00536-1277-80,NDC,outpatient,28,GR,5.24,3.668,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,49348-0521-72,NDC,outpatient,28.4,GR,6.32,4.424,AETNA [1000108],AETNA [100010801],,,76.8,,4.85,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00096-0732-04,NDC,outpatient,120,ML,56.61,39.627,AETNA [1000108],AETNA [100010801],,,76.8,,43.48,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00394-0859-32,NDC,outpatient,114,ML,22.83,15.981,AETNA [1000108],AETNA [100010801],,,76.8,,17.53,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,S5000,HCPCS,259,RC,00168-0020-31,NDC,outpatient,28.35,GR,18.05,12.635,AETNA [1000108],AETNA [100010801],,,76.8,,13.86,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,59762-0074-01,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-01,NDC,outpatient,1,UN,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-11,NDC,outpatient,1,UN,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,10135-0751-12,NDC,outpatient,1,UN,7.8,5.46,AETNA [1000108],AETNA [100010801],,,76.8,,5.99,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,00574-7090-12,NDC,outpatient,1,UN,5.54,3.878,AETNA [1000108],AETNA [100010801],,,76.8,,4.25,0.222255,85118.57664,percent of total billed charges,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-98,NDC,outpatient,1,UN,3.48,2.436,AETNA [1000108],AETNA [100010801],,,76.8,,2.67,0.222255,85118.57664,percent of total billed charges,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-89,NDC,outpatient,1,UN,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-65,NDC,outpatient,1,UN,2.84,1.988,AETNA [1000108],AETNA [100010801],,,76.8,,2.18,0.222255,85118.57664,percent of total billed charges,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-60,NDC,outpatient,1,UN,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-95,NDC,outpatient,1,UN,3.48,2.436,AETNA [1000108],AETNA [100010801],,,76.8,,2.67,0.222255,85118.57664,percent of total billed charges,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-63,NDC,outpatient,1,UN,2.84,1.988,AETNA [1000108],AETNA [100010801],,,76.8,,2.18,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-11,NDC,outpatient,1,UN,7.06,4.942,AETNA [1000108],AETNA [100010801],,,76.8,,5.42,0.222255,85118.57664,percent of total billed charges,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-13,NDC,outpatient,1,UN,7.06,4.942,AETNA [1000108],AETNA [100010801],,,76.8,,5.42,0.222255,85118.57664,percent of total billed charges,
BSS IO SOLN,RX-37579,CDM,S5000,HCPCS,259,RC,00065-0795-15,NDC,outpatient,15,ML,24.7,17.29,AETNA [1000108],AETNA [100010801],,,76.8,,18.97,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-01,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-11,NDC,outpatient,1,UN,1.27,0.889,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-01,NDC,outpatient,1,UN,1.27,0.889,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,00406-3243-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-11,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,42858-0234-01,NDC,outpatient,1,UN,17.03,11.921,AETNA [1000108],AETNA [100010801],,,76.8,,13.08,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,00406-3244-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-01,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,00378-0018-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,23155-0603-51,NDC,outpatient,100,ML,170.44,119.308,AETNA [1000108],AETNA [100010801],,,76.8,,130.9,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,59762-0016-01,NDC,outpatient,100,ML,170.44,119.308,AETNA [1000108],AETNA [100010801],,,76.8,,130.9,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,99999-0002-90,NDC,outpatient,10,ML,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.222255,85118.57664,percent of total billed charges,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-11,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-21,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-11,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-01,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,00904-6718-39,NDC,outpatient,1,UN,2.32,1.624,AETNA [1000108],AETNA [100010801],,,76.8,,1.78,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-01,NDC,outpatient,1,UN,2.76,1.932,AETNA [1000108],AETNA [100010801],,,76.8,,2.12,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-11,NDC,outpatient,1,UN,2.76,1.932,AETNA [1000108],AETNA [100010801],,,76.8,,2.12,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,63824-0008-50,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,54838-0502-80,NDC,outpatient,5,ML,2.88,2.016,AETNA [1000108],AETNA [100010801],,,76.8,,2.21,0.222255,85118.57664,percent of total billed charges,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,62135-0750-47,NDC,outpatient,5,ML,21.74,15.218,AETNA [1000108],AETNA [100010801],,,76.8,,16.7,0.222255,85118.57664,percent of total billed charges,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,99999-0002-50,NDC,outpatient,5,ML,1.16,0.812,AETNA [1000108],AETNA [100010801],,,76.8,,0.89,0.222255,85118.57664,percent of total billed charges,
HYDROXYZINE HCL 10 MG ORAL TABS,RX-3772,CDM,S5000,HCPCS,259,RC,63739-0483-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,63739-0486-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,00904-6617-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TALC 5 G PL SUSR,RX-37812,CDM,S5000,HCPCS,259,RC,63256-0200-05,NDC,outpatient,1,UN,458.35,320.845,AETNA [1000108],AETNA [100010801],,,76.8,,352.01,0.222255,85118.57664,percent of total billed charges,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-11,NDC,outpatient,1,UN,64.87,45.409,AETNA [1000108],AETNA [100010801],,,76.8,,49.82,0.222255,85118.57664,percent of total billed charges,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,00904-7067-04,NDC,outpatient,1,UN,76.53,53.571,AETNA [1000108],AETNA [100010801],,,76.8,,58.78,0.222255,85118.57664,percent of total billed charges,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,55513-0073-30,NDC,outpatient,1,UN,75.45,52.815,AETNA [1000108],AETNA [100010801],,,76.8,,57.95,0.222255,85118.57664,percent of total billed charges,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-21,NDC,outpatient,1,UN,64.87,45.409,AETNA [1000108],AETNA [100010801],,,76.8,,49.82,0.222255,85118.57664,percent of total billed charges,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,70436-0007-04,NDC,outpatient,1,UN,1.94,1.358,AETNA [1000108],AETNA [100010801],,,76.8,,1.49,0.222255,85118.57664,percent of total billed charges,
ORPHENADRINE CITRATE ER 100 MG ORAL TB12,RX-38213,CDM,S5000,HCPCS,259,RC,43386-0480-24,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,00228-2778-11,NDC,outpatient,1,UN,6.75,4.725,AETNA [1000108],AETNA [100010801],,,76.8,,5.18,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,42291-0522-01,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,62559-0530-01,NDC,outpatient,1,UN,2.1,1.47,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00228-2779-11,NDC,outpatient,1,UN,8.57,5.999,AETNA [1000108],AETNA [100010801],,,76.8,,6.58,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00527-4117-37,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,42291-0524-01,NDC,outpatient,1,UN,2.42,1.694,AETNA [1000108],AETNA [100010801],,,76.8,,1.86,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,00228-2780-11,NDC,outpatient,1,UN,10.29,7.203,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.222255,85118.57664,percent of total billed charges,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-00,NDC,outpatient,30,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,99999-0001-83,NDC,outpatient,30,ML,2.16,1.512,AETNA [1000108],AETNA [100010801],,,76.8,,1.66,0.222255,85118.57664,percent of total billed charges,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-30,NDC,outpatient,30,ML,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-65,NDC,outpatient,15,ML,1.01,0.707,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-30,NDC,outpatient,30,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-64,NDC,outpatient,1,UN,12.96,9.072,AETNA [1000108],AETNA [100010801],,,76.8,,9.95,0.222255,85118.57664,percent of total billed charges,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-06,NDC,outpatient,1,UN,12.96,9.072,AETNA [1000108],AETNA [100010801],,,76.8,,9.95,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 200 MG ORAL TABS,RX-3841,CDM,S5000,HCPCS,259,RC,00904-7914-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 600 MG ORAL TABS,RX-3844,CDM,S5000,HCPCS,259,RC,00904-5854-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-09,NDC,outpatient,1,ML,15.58,10.906,AETNA [1000108],AETNA [100010801],,,76.8,,11.97,0.222255,85118.57664,percent of total billed charges,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-01,NDC,outpatient,4,ML,53.96,37.772,AETNA [1000108],AETNA [100010801],,,76.8,,41.44,0.222255,85118.57664,percent of total billed charges,
IBUPROFEN 800 MG ORAL TABS,RX-3845,CDM,S5000,HCPCS,259,RC,00904-5855-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FLUOXETINE HCL 20 MG/5ML ORAL SOLN,RX-38488,CDM,S5000,HCPCS,259,RC,00121-4721-05,NDC,outpatient,5,ML,14.38,10.066,AETNA [1000108],AETNA [100010801],,,76.8,,11.04,0.222255,85118.57664,percent of total billed charges,
IMIPRAMINE HCL 10 MG ORAL TABS,RX-3860,CDM,S5000,HCPCS,259,RC,69584-0425-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IMIPRAMINE HCL 25 MG ORAL TABS,RX-3861,CDM,S5000,HCPCS,259,RC,69584-0426-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,S5000,HCPCS,259,RC,24208-0780-55,NDC,outpatient,3.5,GR,57.59,40.313,AETNA [1000108],AETNA [100010801],,,76.8,,44.23,0.222255,85118.57664,percent of total billed charges,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,00228-2571-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,62559-0511-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SELENIUM SULFIDE 1 % EX SHAM,RX-38961,CDM,S5000,HCPCS,259,RC,00536-1995-53,NDC,outpatient,207,ML,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,0.222255,85118.57664,percent of total billed charges,
PEG 3350-KCL-NABCB-NACL-NASULF 240 G ORAL SOLR,RX-38965,CDM,S5000,HCPCS,259,RC,43386-0060-19,NDC,outpatient,4000,ML,53.4,37.38,AETNA [1000108],AETNA [100010801],,,76.8,,41.01,0.222255,85118.57664,percent of total billed charges,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-15,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-11,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,S5000,HCPCS,259,RC,69344-0102-33,NDC,outpatient,1,UN,1095.8,767.06,AETNA [1000108],AETNA [100010801],,,76.8,,841.57,0.222255,85118.57664,percent of total billed charges,
RIFAXIMIN 200 MG ORAL TABS,RX-39063,CDM,S5000,HCPCS,259,RC,65649-0301-03,NDC,outpatient,1,UN,43.55,30.485,AETNA [1000108],AETNA [100010801],,,76.8,,33.45,0.222255,85118.57664,percent of total billed charges,
AMILORIDE HCL 5 MG ORAL TABS,RX-391,CDM,S5000,HCPCS,259,RC,00574-0292-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,00832-0465-15,NDC,outpatient,15,GR,37.52,26.264,AETNA [1000108],AETNA [100010801],,,76.8,,28.82,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68308-0152-15,NDC,outpatient,15,GR,27.84,19.488,AETNA [1000108],AETNA [100010801],,,76.8,,21.38,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68382-0370-01,NDC,outpatient,15,GR,31.18,21.826,AETNA [1000108],AETNA [100010801],,,76.8,,23.95,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,69315-0306-15,NDC,outpatient,15,GR,24.5,17.15,AETNA [1000108],AETNA [100010801],,,76.8,,18.82,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,16714-0769-01,NDC,outpatient,15,GR,25.04,17.528,AETNA [1000108],AETNA [100010801],,,76.8,,19.23,0.222255,85118.57664,percent of total billed charges,
EMTRICITABINE-TENOFOVIR DF 200-300 MG ORAL TABS,RX-39255,CDM,S5000,HCPCS,259,RC,61958-0701-01,NDC,outpatient,1,UN,265.08,185.556,AETNA [1000108],AETNA [100010801],,,76.8,,203.58,0.222255,85118.57664,percent of total billed charges,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,00904-7043-04,NDC,outpatient,1,UN,3.3,2.31,AETNA [1000108],AETNA [100010801],,,76.8,,2.53,0.222255,85118.57664,percent of total billed charges,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-21,NDC,outpatient,1,UN,3.39,2.373,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-11,NDC,outpatient,1,UN,3.39,2.373,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-01,NDC,outpatient,1,UN,3.41,2.387,AETNA [1000108],AETNA [100010801],,,76.8,,2.62,0.222255,85118.57664,percent of total billed charges,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-11,NDC,outpatient,1,UN,3.41,2.387,AETNA [1000108],AETNA [100010801],,,76.8,,2.62,0.222255,85118.57664,percent of total billed charges,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,57237-0018-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,00904-7044-61,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-93,NDC,outpatient,1,UN,20.14,14.098,AETNA [1000108],AETNA [100010801],,,76.8,,15.47,0.222255,85118.57664,percent of total billed charges,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-31,NDC,outpatient,1,UN,20.14,14.098,AETNA [1000108],AETNA [100010801],,,76.8,,15.47,0.222255,85118.57664,percent of total billed charges,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,65862-0219-60,NDC,outpatient,60,ML,88.92,62.244,AETNA [1000108],AETNA [100010801],,,76.8,,68.29,0.222255,85118.57664,percent of total billed charges,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,99999-0002-80,NDC,outpatient,6,ML,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.222255,85118.57664,percent of total billed charges,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,68180-0723-04,NDC,outpatient,60,ML,87.31,61.117,AETNA [1000108],AETNA [100010801],,,76.8,,67.05,0.222255,85118.57664,percent of total billed charges,
MESALAMINE ER 500 MG ORAL CPCR,RX-39575,CDM,S5000,HCPCS,259,RC,54092-0191-12,NDC,outpatient,1,UN,24.97,17.479,AETNA [1000108],AETNA [100010801],,,76.8,,19.18,0.222255,85118.57664,percent of total billed charges,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,48433-0230-15,NDC,outpatient,14,ML,132.64,92.848,AETNA [1000108],AETNA [100010801],,,76.8,,101.87,0.222255,85118.57664,percent of total billed charges,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,51552-0019-44,NDC,outpatient,14,ML,5.44,3.808,AETNA [1000108],AETNA [100010801],,,76.8,,4.18,0.222255,85118.57664,percent of total billed charges,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-95,NDC,outpatient,1,UN,6.9,4.83,AETNA [1000108],AETNA [100010801],,,76.8,,5.3,0.222255,85118.57664,percent of total billed charges,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-25,NDC,outpatient,1,UN,6.9,4.83,AETNA [1000108],AETNA [100010801],,,76.8,,5.3,0.222255,85118.57664,percent of total billed charges,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-10,NDC,outpatient,5,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-01,NDC,outpatient,5,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-10,NDC,outpatient,5,ML,12.98,9.086,AETNA [1000108],AETNA [100010801],,,76.8,,9.97,0.222255,85118.57664,percent of total billed charges,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-01,NDC,outpatient,5,ML,12.98,9.086,AETNA [1000108],AETNA [100010801],,,76.8,,9.97,0.222255,85118.57664,percent of total billed charges,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,63323-0424-05,NDC,outpatient,5,ML,15.68,10.976,AETNA [1000108],AETNA [100010801],,,76.8,,12.04,0.222255,85118.57664,percent of total billed charges,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,99999-0002-53,NDC,outpatient,10,ML,37.07,25.949,AETNA [1000108],AETNA [100010801],,,76.8,,28.47,0.222255,85118.57664,percent of total billed charges,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,00527-1948-68,NDC,outpatient,10,ML,85.98,60.186,AETNA [1000108],AETNA [100010801],,,76.8,,66.03,0.222255,85118.57664,percent of total billed charges,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-42,NDC,outpatient,1,UN,24.73,17.311,AETNA [1000108],AETNA [100010801],,,76.8,,18.99,0.222255,85118.57664,percent of total billed charges,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-90,NDC,outpatient,1,UN,49.37,34.559,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,0.222255,85118.57664,percent of total billed charges,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-45,NDC,outpatient,1,UN,49.37,34.559,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,0.222255,85118.57664,percent of total billed charges,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-52,NDC,outpatient,1,UN,24.73,17.311,AETNA [1000108],AETNA [100010801],,,76.8,,18.99,0.222255,85118.57664,percent of total billed charges,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-01,NDC,outpatient,1,UN,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-20,NDC,outpatient,1,UN,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,51079-0608-20,NDC,outpatient,1,UN,10.74,7.518,AETNA [1000108],AETNA [100010801],,,76.8,,8.25,0.222255,85118.57664,percent of total billed charges,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,60687-0629-21,NDC,outpatient,1,UN,4.19,2.933,AETNA [1000108],AETNA [100010801],,,76.8,,3.22,0.222255,85118.57664,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-01,NDC,outpatient,10,ML,19.54,13.678,AETNA [1000108],AETNA [100010801],,,76.8,,15.01,0.222255,85118.57664,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-04,NDC,outpatient,5,ML,14,9.8,AETNA [1000108],AETNA [100010801],,,76.8,,10.75,0.222255,85118.57664,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-82,NDC,outpatient,10,ML,19.54,13.678,AETNA [1000108],AETNA [100010801],,,76.8,,15.01,0.222255,85118.57664,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-61,NDC,outpatient,180,ML,12.46,8.722,AETNA [1000108],AETNA [100010801],,,76.8,,9.57,0.222255,85118.57664,percent of total billed charges,
RIFAMPIN 10 MG/ML ORAL SUSPENSION,RX-400484,CDM,S5000,HCPCS,259,RC,99999-0001-44,NDC,outpatient,120,ML,34,23.8,AETNA [1000108],AETNA [100010801],,,76.8,,26.11,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,,,outpatient,12.5,ME,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,99999-0002-12,NDC,outpatient,12.5,ME,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,SH040-0403-01,NDC,outpatient,12.5,ME,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CEFAZOLIN EYE DROPS 50 MG/ML 20 ML BOTTLE,RX-400598,CDM,S5000,HCPCS,259,RC,SH408-0378-01,NDC,outpatient,20,ML,18.41,12.887,AETNA [1000108],AETNA [100010801],,,76.8,,14.14,0.222255,85118.57664,percent of total billed charges,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,,,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,SH040-0620-01,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,
ISONIAZID 100 MG ORAL TABS,RX-4026,CDM,S5000,HCPCS,259,RC,00555-0066-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-25,NDC,outpatient,4,ML,8,5.6,AETNA [1000108],AETNA [100010801],,,76.8,,6.14,0.222255,85118.57664,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-16,NDC,outpatient,20,ML,18.34,12.838,AETNA [1000108],AETNA [100010801],,,76.8,,14.09,0.222255,85118.57664,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-73,NDC,outpatient,20,ML,18.34,12.838,AETNA [1000108],AETNA [100010801],,,76.8,,14.09,0.222255,85118.57664,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-01,NDC,outpatient,4,ML,8,5.6,AETNA [1000108],AETNA [100010801],,,76.8,,6.14,0.222255,85118.57664,percent of total billed charges,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,00548-9502-00,NDC,outpatient,5,ML,246.51,172.557,AETNA [1000108],AETNA [100010801],,,76.8,,189.32,0.222255,85118.57664,percent of total billed charges,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-07,NDC,outpatient,5,ML,1453.64,1017.548,AETNA [1000108],AETNA [100010801],,,76.8,,1116.4,0.222255,85118.57664,percent of total billed charges,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-05,NDC,outpatient,5,ML,1453.64,1017.548,AETNA [1000108],AETNA [100010801],,,76.8,,1116.4,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,69918-0560-30,NDC,outpatient,1,UN,7.56,5.292,AETNA [1000108],AETNA [100010801],,,76.8,,5.81,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,59762-0118-03,NDC,outpatient,1,UN,22.5,15.75,AETNA [1000108],AETNA [100010801],,,76.8,,17.28,0.222255,85118.57664,percent of total billed charges,
SOLIFENACIN SUCCINATE 5 MG ORAL TABS,RX-40392,CDM,S5000,HCPCS,259,RC,51248-0150-01,NDC,outpatient,1,UN,52.84,36.988,AETNA [1000108],AETNA [100010801],,,76.8,,40.58,0.222255,85118.57664,percent of total billed charges,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,74312-0035-95,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,00743-1203-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-11,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG ORAL TABS,RX-4065,CDM,S5000,HCPCS,259,RC,00904-6620-61,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-20,NDC,outpatient,250,ML,30.14,21.098,AETNA [1000108],AETNA [100010801],,,76.8,,23.15,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-10,NDC,outpatient,500,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.222255,85118.57664,percent of total billed charges,
HYDROMORPHONE 100 MG/100 ML INFUSION,RX-4080055,CDM,S5000,HCPCS,250,RC,99999-0000-26,NDC,outpatient,100,ML,168.65,118.055,AETNA [1000108],AETNA [100010801],,,76.8,,129.52,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM ADDVANTAGE INFUSION IN NS,RX-4080056,CDM,S5000,HCPCS,250,RC,99999-0000-00,NDC,outpatient,100,ML,54.5,38.15,AETNA [1000108],AETNA [100010801],,,76.8,,41.86,0.222255,85118.57664,percent of total billed charges,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0229-40,NDC,outpatient,250,ML,277.66,194.362,AETNA [1000108],AETNA [100010801],,,76.8,,213.24,0.222255,85118.57664,percent of total billed charges,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,99999-0001-54,NDC,outpatient,250,ML,37.36,26.152,AETNA [1000108],AETNA [100010801],,,76.8,,28.69,0.222255,85118.57664,percent of total billed charges,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70092-1093-37,NDC,outpatient,250,ML,130.86,91.602,AETNA [1000108],AETNA [100010801],,,76.8,,100.5,0.222255,85118.57664,percent of total billed charges,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0202-40,NDC,outpatient,250,ML,236.1,165.27,AETNA [1000108],AETNA [100010801],,,76.8,,181.32,0.222255,85118.57664,percent of total billed charges,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,70004-0442-40,NDC,outpatient,250,ML,112.79,78.953,AETNA [1000108],AETNA [100010801],,,76.8,,86.62,0.222255,85118.57664,percent of total billed charges,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,99999-9990-03,NDC,outpatient,250,ML,37.81,26.467,AETNA [1000108],AETNA [100010801],,,76.8,,29.04,0.222255,85118.57664,percent of total billed charges,
MORPHINE INFUSION 250 MG IN D5W 250 ML PREMIX,RX-4080096,CDM,S5000,HCPCS,250,RC,99999-0001-61,NDC,outpatient,250,ML,35.02,24.514,AETNA [1000108],AETNA [100010801],,,76.8,,26.9,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-01,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-00,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-25,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-22,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,57896-0181-05,NDC,outpatient,15,ML,5.55,3.885,AETNA [1000108],AETNA [100010801],,,76.8,,4.26,0.222255,85118.57664,percent of total billed charges,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,00065-0426-36,NDC,outpatient,15,ML,27.17,19.019,AETNA [1000108],AETNA [100010801],,,76.8,,20.87,0.222255,85118.57664,percent of total billed charges,
NAFCILLIN SODIUM 1 G IJ WRAPPER,RX-4080106,CDM,S5000,HCPCS,250,RC,63323-0327-10,NDC,outpatient,1,UN,15.49,10.843,AETNA [1000108],AETNA [100010801],,,76.8,,11.9,0.222255,85118.57664,percent of total billed charges,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,44567-0222-10,NDC,outpatient,1,UN,90.46,63.322,AETNA [1000108],AETNA [100010801],,,76.8,,69.47,0.222255,85118.57664,percent of total billed charges,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,55150-0123-15,NDC,outpatient,1,UN,30.45,21.315,AETNA [1000108],AETNA [100010801],,,76.8,,23.39,0.222255,85118.57664,percent of total billed charges,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,63323-0328-20,NDC,outpatient,1,UN,24.64,17.248,AETNA [1000108],AETNA [100010801],,,76.8,,18.92,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,71266-5020-02,NDC,outpatient,250,ML,112.97,79.079,AETNA [1000108],AETNA [100010801],,,76.8,,86.76,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70004-0781-40,NDC,outpatient,250,ML,123.78,86.646,AETNA [1000108],AETNA [100010801],,,76.8,,95.06,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70092-1650-05,NDC,outpatient,250,ML,102.2,71.54,AETNA [1000108],AETNA [100010801],,,76.8,,78.49,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,42852-0838-25,NDC,outpatient,250,ML,158.85,111.195,AETNA [1000108],AETNA [100010801],,,76.8,,122,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70004-0812-40,NDC,outpatient,250,ML,93.12,65.184,AETNA [1000108],AETNA [100010801],,,76.8,,71.52,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70092-9170-05,NDC,outpatient,250,ML,146.26,102.382,AETNA [1000108],AETNA [100010801],,,76.8,,112.33,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,70004-0811-40,NDC,outpatient,250,ML,109.23,76.461,AETNA [1000108],AETNA [100010801],,,76.8,,83.89,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,71506-0010-58,NDC,outpatient,250,ML,88.76,62.132,AETNA [1000108],AETNA [100010801],,,76.8,,68.17,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 1250 MG/250 ML IV SOLN,RX-4080122,CDM,S5000,HCPCS,250,RC,99999-0000-46,NDC,outpatient,275,ML,64.38,45.066,AETNA [1000108],AETNA [100010801],,,76.8,,49.44,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 1500 MG/250 ML IV SOLN,RX-4080123,CDM,S5000,HCPCS,250,RC,99999-0000-47,NDC,outpatient,280,ML,80.8,56.56,AETNA [1000108],AETNA [100010801],,,76.8,,62.05,0.222255,85118.57664,percent of total billed charges,
CARDIOPLEGIA SOLN HIGH POTASSIUM 4:1 INDUCTION,RX-4080154,CDM,S5000,HCPCS,250,RC,72196-0101-01,NDC,outpatient,500,ML,673.36,471.352,AETNA [1000108],AETNA [100010801],,,76.8,,517.14,0.222255,85118.57664,percent of total billed charges,
CARDIOPLEGIA SOLN LOW POTASSION 4:1 REPERFUSATE,RX-4080155,CDM,S5000,HCPCS,250,RC,71285-0007-01,NDC,outpatient,238.75,ML,1537.64,1076.348,AETNA [1000108],AETNA [100010801],,,76.8,,1180.91,0.222255,85118.57664,percent of total billed charges,
CARDIOPLEGIA SOLN LOW POTASSIUM 4:1 MAINTENANCE,RX-4080156,CDM,S5000,HCPCS,250,RC,72196-0104-01,NDC,outpatient,1000,ML,1042.09,729.463,AETNA [1000108],AETNA [100010801],,,76.8,,800.33,0.222255,85118.57664,percent of total billed charges,
CONCENTRATED DILAUDID 1 MG/ML PCA,RX-4080157,CDM,S5000,HCPCS,250,RC,70004-0303-62,NDC,outpatient,50,ML,212.25,148.575,AETNA [1000108],AETNA [100010801],,,76.8,,163.01,0.222255,85118.57664,percent of total billed charges,
DILAUDID 0.2 MG/ML PCA (HYDROMORPHONE),RX-4080159,CDM,S5000,HCPCS,250,RC,70004-0300-62,NDC,outpatient,50,ML,69.63,48.741,AETNA [1000108],AETNA [100010801],,,76.8,,53.48,0.222255,85118.57664,percent of total billed charges,
PRISMASATE K 0/CA 3.5 CRRT SOLUTION,RX-4080163,CDM,S5000,HCPCS,250,RC,00000-1053-53,NDC,outpatient,5000,ML,188.44,131.908,AETNA [1000108],AETNA [100010801],,,76.8,,144.72,0.222255,85118.57664,percent of total billed charges,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,99999-0001-52,NDC,outpatient,100,ML,30.84,21.588,AETNA [1000108],AETNA [100010801],,,76.8,,23.69,0.222255,85118.57664,percent of total billed charges,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70004-0231-64,NDC,outpatient,100,ML,109.23,76.461,AETNA [1000108],AETNA [100010801],,,76.8,,83.89,0.222255,85118.57664,percent of total billed charges,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-1202-75,NDC,outpatient,100,ML,258.44,180.908,AETNA [1000108],AETNA [100010801],,,76.8,,198.48,0.222255,85118.57664,percent of total billed charges,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-9202-75,NDC,outpatient,100,ML,251.94,176.358,AETNA [1000108],AETNA [100010801],,,76.8,,193.49,0.222255,85118.57664,percent of total billed charges,
FENTANYL 5 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080169,CDM,S5000,HCPCS,250,RC,99999-0001-55,NDC,outpatient,100,ML,34.55,24.185,AETNA [1000108],AETNA [100010801],,,76.8,,26.53,0.222255,85118.57664,percent of total billed charges,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080170,CDM,S5000,HCPCS,250,RC,99999-0000-03,NDC,outpatient,100,ML,67.18,47.026,AETNA [1000108],AETNA [100010801],,,76.8,,51.59,0.222255,85118.57664,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-12,NDC,outpatient,2,ML,6.33,4.431,AETNA [1000108],AETNA [100010801],,,76.8,,4.86,0.222255,85118.57664,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-22,NDC,outpatient,2,ML,6.33,4.431,AETNA [1000108],AETNA [100010801],,,76.8,,4.86,0.222255,85118.57664,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-21,NDC,outpatient,1,ML,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-01,NDC,outpatient,1,ML,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,70004-0756-12,NDC,outpatient,10,ML,39.83,27.881,AETNA [1000108],AETNA [100010801],,,76.8,,30.59,0.222255,85118.57664,percent of total billed charges,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,99999-0001-50,NDC,outpatient,10,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-10,NDC,outpatient,10,ML,22.61,15.827,AETNA [1000108],AETNA [100010801],,,76.8,,17.36,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-01,NDC,outpatient,10,ML,22.61,15.827,AETNA [1000108],AETNA [100010801],,,76.8,,17.36,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-10,NDC,outpatient,5,ML,14.35,10.045,AETNA [1000108],AETNA [100010801],,,76.8,,11.02,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-01,NDC,outpatient,5,ML,14.35,10.045,AETNA [1000108],AETNA [100010801],,,76.8,,11.02,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE-LIDOCAINE 0.3%-1.5% OINT,RX-408020,CDM,S5000,HCPCS,259,RC,00000-0000-03,NDC,outpatient,30,GR,333.75,233.625,AETNA [1000108],AETNA [100010801],,,76.8,,256.32,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-05,NDC,outpatient,5,ML,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-15,NDC,outpatient,5,ML,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,71399-2829-01,NDC,outpatient,28,GR,14.21,9.947,AETNA [1000108],AETNA [100010801],,,76.8,,10.91,0.222255,85118.57664,percent of total billed charges,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,00536-1211-95,NDC,outpatient,28,GR,13.84,9.688,AETNA [1000108],AETNA [100010801],,,76.8,,10.63,0.222255,85118.57664,percent of total billed charges,
COCOA BUTTER STICK,RX-4080278,CDM,S5000,HCPCS,259,RC,07570-7011-00,NDC,outpatient,30,ML,4.41,3.087,AETNA [1000108],AETNA [100010801],,,76.8,,3.39,0.222255,85118.57664,percent of total billed charges,
CAPSAICIN 0.025 % EX CREAM WRAPPER,RX-4080289,CDM,S5000,HCPCS,259,RC,00536-2525-25,NDC,outpatient,60,GR,10.95,7.665,AETNA [1000108],AETNA [100010801],,,76.8,,8.41,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,00168-0357-55,NDC,outpatient,5,GR,29.95,20.965,AETNA [1000108],AETNA [100010801],,,76.8,,23,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-04,NDC,outpatient,5,GR,24.68,17.276,AETNA [1000108],AETNA [100010801],,,76.8,,18.95,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-31,NDC,outpatient,30,GR,87.18,61.026,AETNA [1000108],AETNA [100010801],,,76.8,,66.95,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,SH408-0358-01,NDC,outpatient,20,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,99999-0000-54,NDC,outpatient,20,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,
MULTIVITAMIN CHILDRENS ORAL CHEW WRAPPER,RX-4080360,CDM,S5000,HCPCS,259,RC,80681-0049-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMPHOTERICIN B EYE DROPS 0.2 MG/ML 10 ML BOTTLE,RX-4080376,CDM,S5000,HCPCS,259,RC,SH408-0376-01,NDC,outpatient,10,ML,61.86,43.302,AETNA [1000108],AETNA [100010801],,,76.8,,47.51,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 1 MG/ML ORAL SUSPENSION 81 ML FOR ASA DESENSITIZATION,RX-4080380,CDM,S5000,HCPCS,259,RC,SH408-0380-01,NDC,outpatient,81,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CEFTAZIDIME EYE DROPS 22.5 MG/ML SYRINGE,RX-4080386,CDM,S5000,HCPCS,259,RC,99999-0000-32,NDC,outpatient,1,ML,37.46,26.222,AETNA [1000108],AETNA [100010801],,,76.8,,28.77,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN MOUTH WASH 3 MG/ML,RX-4080388,CDM,S5000,HCPCS,259,RC,99999-0000-33,NDC,outpatient,250,ML,10.02,7.014,AETNA [1000108],AETNA [100010801],,,76.8,,7.7,0.222255,85118.57664,percent of total billed charges,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,70092-1135-44,NDC,outpatient,3,ML,49.22,34.454,AETNA [1000108],AETNA [100010801],,,76.8,,37.8,0.222255,85118.57664,percent of total billed charges,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,88888-0926-28,NDC,outpatient,3,ML,22.25,15.575,AETNA [1000108],AETNA [100010801],,,76.8,,17.09,0.222255,85118.57664,percent of total billed charges,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,69623-0801-14,NDC,outpatient,3,ML,35.6,24.92,AETNA [1000108],AETNA [100010801],,,76.8,,27.34,0.222255,85118.57664,percent of total billed charges,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,99999-0003-19,NDC,outpatient,3,ML,14.57,10.199,AETNA [1000108],AETNA [100010801],,,76.8,,11.19,0.222255,85118.57664,percent of total billed charges,
MAG SULFATE-GLYCERIN-WATER ENEMA 180 ML,RX-4080412,CDM,S5000,HCPCS,259,RC,00000-0000-02,NDC,outpatient,180,ML,28.04,19.628,AETNA [1000108],AETNA [100010801],,,76.8,,21.53,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE ORAL SUSPENSION 1 MG/ML,RX-4080416,CDM,S5000,HCPCS,259,RC,99999-0003-46,NDC,outpatient,12.5,ML,1.93,1.351,AETNA [1000108],AETNA [100010801],,,76.8,,1.48,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-37,NDC,outpatient,240,ML,1184.42,829.094,AETNA [1000108],AETNA [100010801],,,76.8,,909.63,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,69238-2122-20,NDC,outpatient,20,ML,14.96,10.472,AETNA [1000108],AETNA [100010801],,,76.8,,11.49,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-35,NDC,outpatient,20,ML,13.44,9.408,AETNA [1000108],AETNA [100010801],,,76.8,,10.32,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-20,NDC,outpatient,20,ML,13.44,9.408,AETNA [1000108],AETNA [100010801],,,76.8,,10.32,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0885-16,NDC,outpatient,480,ML,1149.17,804.419,AETNA [1000108],AETNA [100010801],,,76.8,,882.56,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-36,NDC,outpatient,5,ML,2.94,2.058,AETNA [1000108],AETNA [100010801],,,76.8,,2.26,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-08,NDC,outpatient,237,ML,159.26,111.482,AETNA [1000108],AETNA [100010801],,,76.8,,122.31,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,42799-0815-01,NDC,outpatient,237,ML,151.87,106.309,AETNA [1000108],AETNA [100010801],,,76.8,,116.64,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-20,NDC,outpatient,20,ML,98.71,69.097,AETNA [1000108],AETNA [100010801],,,76.8,,75.81,0.222255,85118.57664,percent of total billed charges,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,99999-0001-12,NDC,outpatient,1,ML,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,SH408-0423-01,NDC,outpatient,1,ML,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 1 MEQ/ML 1 ML ORAL SYRINGE,RX-4080424,CDM,S5000,HCPCS,259,RC,99999-0001-25,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE-MINERAL OIL-GLYCERIN ENEMA,RX-4080430,CDM,S5000,HCPCS,259,RC,SH408-0430-01,NDC,outpatient,135,ML,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,,,outpatient,1.5,ML,1.92,1.344,AETNA [1000108],AETNA [100010801],,,76.8,,1.47,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,99999-0001-26,NDC,outpatient,1.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SPIRONOLACTONE 6 MG/3 ML ORAL SYRINGE,RX-4080435,CDM,S5000,HCPCS,259,RC,99999-0000-28,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CEFAZOLIN IVPB 2 G IN 100 ML NS PREMIX,RX-4080437,CDM,S5000,HCPCS,250,RC,99999-0000-45,NDC,outpatient,100,ML,47.78,33.446,AETNA [1000108],AETNA [100010801],,,76.8,,36.7,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0450-01,NDC,outpatient,0.1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0449-01,NDC,outpatient,2,ML,22.21,15.547,AETNA [1000108],AETNA [100010801],,,76.8,,17.06,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN EYE SOLUTION 25 MG/ML,RX-4080451,CDM,S5000,HCPCS,259,RC,SH408-0451-01,NDC,outpatient,20,ML,54.07,37.849,AETNA [1000108],AETNA [100010801],,,76.8,,41.53,0.222255,85118.57664,percent of total billed charges,
VANCOMYCIN EYE SOLUTION 50 MG/ML ,RX-4080452,CDM,S5000,HCPCS,259,RC,SH408-0452-01,NDC,outpatient,20,ML,54.07,37.849,AETNA [1000108],AETNA [100010801],,,76.8,,41.53,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,51672-4027-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,76282-0327-01,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,99999-0002-46,NDC,outpatient,0.5,ME,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,51672-4029-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,99999-0002-47,NDC,outpatient,1.25,ME,4.53,3.171,AETNA [1000108],AETNA [100010801],,,76.8,,3.48,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0775-40,NDC,outpatient,250,ML,320.83,224.581,AETNA [1000108],AETNA [100010801],,,76.8,,246.4,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-03,NDC,outpatient,250,ML,261.87,183.309,AETNA [1000108],AETNA [100010801],,,76.8,,201.12,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0533-25,NDC,outpatient,250,ML,140.6,98.42,AETNA [1000108],AETNA [100010801],,,76.8,,107.98,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1652-05,NDC,outpatient,250,ML,216.97,151.879,AETNA [1000108],AETNA [100010801],,,76.8,,166.63,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-01,NDC,outpatient,250,ML,261.87,183.309,AETNA [1000108],AETNA [100010801],,,76.8,,201.12,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0315-25,NDC,outpatient,250,ML,118.35,82.845,AETNA [1000108],AETNA [100010801],,,76.8,,90.89,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1468-05,NDC,outpatient,250,ML,192.22,134.554,AETNA [1000108],AETNA [100010801],,,76.8,,147.62,0.222255,85118.57664,percent of total billed charges,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0785-40,NDC,outpatient,250,ML,301.03,210.721,AETNA [1000108],AETNA [100010801],,,76.8,,231.19,0.222255,85118.57664,percent of total billed charges,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,00904-7191-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,48433-0108-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70004-0750-09,NDC,outpatient,5,ML,78.06,54.642,AETNA [1000108],AETNA [100010801],,,76.8,,59.95,0.222255,85118.57664,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-13,NDC,outpatient,3,ML,51.74,36.218,AETNA [1000108],AETNA [100010801],,,76.8,,39.74,0.222255,85118.57664,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-30,NDC,outpatient,3,ML,51.74,36.218,AETNA [1000108],AETNA [100010801],,,76.8,,39.74,0.222255,85118.57664,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,69374-0932-03,NDC,outpatient,3,ML,45.62,31.934,AETNA [1000108],AETNA [100010801],,,76.8,,35.04,0.222255,85118.57664,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70092-1084-44,NDC,outpatient,5,ML,61.01,42.707,AETNA [1000108],AETNA [100010801],,,76.8,,46.86,0.222255,85118.57664,percent of total billed charges,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,00574-0508-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,20555-0019-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,00065-0518-01,NDC,outpatient,3.5,GR,29.43,20.601,AETNA [1000108],AETNA [100010801],,,76.8,,22.6,0.222255,85118.57664,percent of total billed charges,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,10119-0022-39,NDC,outpatient,3.5,GR,30.17,21.119,AETNA [1000108],AETNA [100010801],,,76.8,,23.17,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 1 % FOR PLEURODESIS,RX-4080551,CDM,S5000,HCPCS,250,RC,99999-0003-43,NDC,outpatient,50,ML,13.37,9.359,AETNA [1000108],AETNA [100010801],,,76.8,,10.27,0.222255,85118.57664,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-01,NDC,outpatient,15,ML,59.41,41.587,AETNA [1000108],AETNA [100010801],,,76.8,,45.63,0.222255,85118.57664,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-09,NDC,outpatient,5,ML,93.68,65.576,AETNA [1000108],AETNA [100010801],,,76.8,,71.95,0.222255,85118.57664,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-11,NDC,outpatient,15,ML,59.41,41.587,AETNA [1000108],AETNA [100010801],,,76.8,,45.63,0.222255,85118.57664,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-29,NDC,outpatient,5,ML,93.68,65.576,AETNA [1000108],AETNA [100010801],,,76.8,,71.95,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,AETNA [1000108],AETNA [100010801],,,76.8,,7.54,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,AETNA [1000108],AETNA [100010801],,,76.8,,7.54,0.222255,85118.57664,percent of total billed charges,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,00799-0001-04,NDC,outpatient,113,GR,20.12,14.084,AETNA [1000108],AETNA [100010801],,,76.8,,15.45,0.222255,85118.57664,percent of total billed charges,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,10135-0701-04,NDC,outpatient,113,GR,13.58,9.506,AETNA [1000108],AETNA [100010801],,,76.8,,10.43,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM 100 MG ADDVANTAGE INFUSION IN D5W 100 ML,RX-4080558,CDM,S5000,HCPCS,250,RC,99999-0000-01,NDC,outpatient,100,ML,48.09,33.663,AETNA [1000108],AETNA [100010801],,,76.8,,36.93,0.222255,85118.57664,percent of total billed charges,
HIV POST EXPOSURE KIT,RX-4080559,CDM,S5000,HCPCS,259,RC,SH408-0559-01,NDC,outpatient,1,UN,1178.97,825.279,AETNA [1000108],AETNA [100010801],,,76.8,,905.45,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE 0.125 % IN 100 ML NS NERVE BLOCK CASSETTE,RX-4080570,CDM,S5000,HCPCS,250,RC,61553-0829-48,NDC,outpatient,100,ML,76.93,53.851,AETNA [1000108],AETNA [100010801],,,76.8,,59.08,0.222255,85118.57664,percent of total billed charges,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080589,CDM,S5000,HCPCS,250,RC,99999-0000-04,NDC,outpatient,100,ML,79.95,55.965,AETNA [1000108],AETNA [100010801],,,76.8,,61.4,0.222255,85118.57664,percent of total billed charges,
VEIN GRAFT SOLUTION,RX-4080591,CDM,S5000,HCPCS,250,RC,99999-0000-07,NDC,outpatient,505.67,ML,73.5,51.45,AETNA [1000108],AETNA [100010801],,,76.8,,56.45,0.222255,85118.57664,percent of total billed charges,
FLECAINIDE ACETATE 20 MG/ML ORAL SUSP,RX-4080607,CDM,S5000,HCPCS,259,RC,99999-0003-52,NDC,outpatient,2.5,ML,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG SL SUBL WRAPPER,RX-4080632,CDM,S5000,HCPCS,259,RC,42192-0338-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-46,NDC,outpatient,60,ML,33.11,23.177,AETNA [1000108],AETNA [100010801],,,76.8,,25.43,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0923-41,NDC,outpatient,60,ML,80.91,56.637,AETNA [1000108],AETNA [100010801],,,76.8,,62.14,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-51,NDC,outpatient,60,ML,33.11,23.177,AETNA [1000108],AETNA [100010801],,,76.8,,25.43,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,10006-0700-28,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM GLUCONATE 500 MG ORAL TABS WRAPPER,RX-4080642,CDM,S5000,HCPCS,259,RC,60258-0172-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GI COCKTAIL SUSPENSION,RX-4080647,CDM,S5000,HCPCS,259,RC,99999-0000-39,NDC,outpatient,55,ML,82.33,57.631,AETNA [1000108],AETNA [100010801],,,76.8,,63.23,0.222255,85118.57664,percent of total billed charges,
CARDIOPLEGIA SOLN DEL NIDO,RX-4080676,CDM,S5000,HCPCS,250,RC,99999-0004-39,NDC,outpatient,1052.8,ML,113.01,79.107,AETNA [1000108],AETNA [100010801],,,76.8,,86.79,0.222255,85118.57664,percent of total billed charges,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1512-46,NDC,outpatient,10,ML,20.96,14.672,AETNA [1000108],AETNA [100010801],,,76.8,,16.1,0.222255,85118.57664,percent of total billed charges,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1617-46,NDC,outpatient,10,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN MINI-BAG 100 ML,RX-4080711,CDM,S5000,HCPCS,250,RC,00338-0553-18,NDC,outpatient,100,ML,29.37,20.559,AETNA [1000108],AETNA [100010801],,,76.8,,22.56,0.222255,85118.57664,percent of total billed charges,
HYDROCORTISONE ORAL SUSPENSION 2.5 MG/ML COMPOUNDED PRODUCT,RX-4080716,CDM,S5000,HCPCS,259,RC,99999-0000-80,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
FLUDROCORTISONE ACETATE SUSP 0.2 MG/ML,RX-4080718,CDM,S5000,HCPCS,259,RC,99999-0000-81,NDC,outpatient,1,ML,4.96,3.472,AETNA [1000108],AETNA [100010801],,,76.8,,3.81,0.222255,85118.57664,percent of total billed charges,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,62103-0323-02,NDC,outpatient,57,GR,14.72,10.304,AETNA [1000108],AETNA [100010801],,,76.8,,11.3,0.222255,85118.57664,percent of total billed charges,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,74300-0000-71,NDC,outpatient,113,GR,26.15,18.305,AETNA [1000108],AETNA [100010801],,,76.8,,20.08,0.222255,85118.57664,percent of total billed charges,
NALOXONE INHALATION KIT - HOSPITAL USE ONLY,RX-4080774,CDM,S5000,HCPCS,259,RC,99999-0000-90,NDC,outpatient,1,UN,110.81,77.567,AETNA [1000108],AETNA [100010801],,,76.8,,85.1,0.222255,85118.57664,percent of total billed charges,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-11,NDC,outpatient,20,ML,230.78,161.546,AETNA [1000108],AETNA [100010801],,,76.8,,177.24,0.222255,85118.57664,percent of total billed charges,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-01,NDC,outpatient,20,ML,230.78,161.546,AETNA [1000108],AETNA [100010801],,,76.8,,177.24,0.222255,85118.57664,percent of total billed charges,
CEFAZOLIN IVPB 3 G IN 100 ML NS PREMIX,RX-4080801,CDM,S5000,HCPCS,250,RC,99999-0001-10,NDC,outpatient,130,ML,33.43,23.401,AETNA [1000108],AETNA [100010801],,,76.8,,25.67,0.222255,85118.57664,percent of total billed charges,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,70092-1433-50,NDC,outpatient,50,ML,216.36,151.452,AETNA [1000108],AETNA [100010801],,,76.8,,166.16,0.222255,85118.57664,percent of total billed charges,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,99999-0000-98,NDC,outpatient,50,ML,59.06,41.342,AETNA [1000108],AETNA [100010801],,,76.8,,45.36,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 5 % MOUTHWASH ORAL SUSPENSION,RX-4080811,CDM,S5000,HCPCS,259,RC,99999-0001-06,NDC,outpatient,169,ML,77.47,54.229,AETNA [1000108],AETNA [100010801],,,76.8,,59.5,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,50580-0170-05,NDC,outpatient,5,ML,1.37,0.959,AETNA [1000108],AETNA [100010801],,,76.8,,1.05,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,99999-0001-17,NDC,outpatient,5,ML,1.37,0.959,AETNA [1000108],AETNA [100010801],,,76.8,,1.05,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,00045-0166-04,NDC,outpatient,120,ML,28.31,19.817,AETNA [1000108],AETNA [100010801],,,76.8,,21.74,0.222255,85118.57664,percent of total billed charges,
BABY BUTT BALM,RX-4080852,CDM,S5000,HCPCS,259,RC,99999-0001-13,NDC,outpatient,118.7,GR,70.96,49.672,AETNA [1000108],AETNA [100010801],,,76.8,,54.5,0.222255,85118.57664,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML SUSPENSION,RX-4080874,CDM,S5000,HCPCS,259,RC,99999-0001-21,NDC,outpatient,5,ML,10.93,7.651,AETNA [1000108],AETNA [100010801],,,76.8,,8.39,0.222255,85118.57664,percent of total billed charges,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-61,NDC,outpatient,15,ML,7.68,5.376,AETNA [1000108],AETNA [100010801],,,76.8,,5.9,0.222255,85118.57664,percent of total billed charges,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-59,NDC,outpatient,15,ML,7.68,5.376,AETNA [1000108],AETNA [100010801],,,76.8,,5.9,0.222255,85118.57664,percent of total billed charges,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-30,NDC,outpatient,15,ML,2.32,1.624,AETNA [1000108],AETNA [100010801],,,76.8,,1.78,0.222255,85118.57664,percent of total billed charges,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00005-4344-62,NDC,outpatient,15,ML,2.09,1.463,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-15,NDC,outpatient,15,ML,2.32,1.624,AETNA [1000108],AETNA [100010801],,,76.8,,1.78,0.222255,85118.57664,percent of total billed charges,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,69618-0008-58,NDC,outpatient,15,ML,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,99999-0002-20,NDC,outpatient,15,ML,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,38779-1284-08,NDC,outpatient,8,ML,2.35,1.645,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-02,NDC,outpatient,8,ML,9.33,6.531,AETNA [1000108],AETNA [100010801],,,76.8,,7.17,0.222255,85118.57664,percent of total billed charges,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-08,NDC,outpatient,8,ML,47.67,33.369,AETNA [1000108],AETNA [100010801],,,76.8,,36.61,0.222255,85118.57664,percent of total billed charges,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,49452-3081-02,NDC,outpatient,8,ML,2.35,1.645,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0170-05,NDC,outpatient,5,ML,35.56,24.892,AETNA [1000108],AETNA [100010801],,,76.8,,27.31,0.222255,85118.57664,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-01,NDC,outpatient,15,ML,169.35,118.545,AETNA [1000108],AETNA [100010801],,,76.8,,130.06,0.222255,85118.57664,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-16,NDC,outpatient,15,ML,169.35,118.545,AETNA [1000108],AETNA [100010801],,,76.8,,130.06,0.222255,85118.57664,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-01,NDC,outpatient,5,ML,79.73,55.811,AETNA [1000108],AETNA [100010801],,,76.8,,61.23,0.222255,85118.57664,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-06,NDC,outpatient,5,ML,79.73,55.811,AETNA [1000108],AETNA [100010801],,,76.8,,61.23,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,43066-0007-10,NDC,outpatient,5,ML,8.46,5.922,AETNA [1000108],AETNA [100010801],,,76.8,,6.5,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-02,NDC,outpatient,5,ML,7.05,4.935,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,67457-0228-02,NDC,outpatient,5,ML,6.84,4.788,AETNA [1000108],AETNA [100010801],,,76.8,,5.25,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-01,NDC,outpatient,5,ML,10.46,7.322,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,25021-0662-05,NDC,outpatient,5,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0225-05,NDC,outpatient,5,ML,9.23,6.461,AETNA [1000108],AETNA [100010801],,,76.8,,7.09,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-05,NDC,outpatient,10,ML,22.61,15.827,AETNA [1000108],AETNA [100010801],,,76.8,,17.36,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-06,NDC,outpatient,10,ML,22.61,15.827,AETNA [1000108],AETNA [100010801],,,76.8,,17.36,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0226-10,NDC,outpatient,10,ML,18.46,12.922,AETNA [1000108],AETNA [100010801],,,76.8,,14.18,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-01,NDC,outpatient,5,ML,24.17,16.919,AETNA [1000108],AETNA [100010801],,,76.8,,18.56,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-10,NDC,outpatient,5,ML,24.17,16.919,AETNA [1000108],AETNA [100010801],,,76.8,,18.56,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-10,NDC,outpatient,5,ML,10.46,7.322,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-05,NDC,outpatient,5,ML,7.05,4.935,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,66794-0228-41,NDC,outpatient,5,ML,6.84,4.788,AETNA [1000108],AETNA [100010801],,,76.8,,5.25,0.222255,85118.57664,percent of total billed charges,
AMIODARONE ORAL SUSPENSION 40 MG/ML,RX-4080970,CDM,S5000,HCPCS,259,RC,99999-0001-63,NDC,outpatient,10,ML,2.04,1.428,AETNA [1000108],AETNA [100010801],,,76.8,,1.57,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 100 MG/100 ML IN D5W PF PREMIX,RX-4081012,CDM,S5000,HCPCS,250,RC,99999-0000-99,NDC,outpatient,100,ML,312.37,218.659,AETNA [1000108],AETNA [100010801],,,76.8,,239.9,0.222255,85118.57664,percent of total billed charges,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,42023-0243-01,NDC,outpatient,10,ML,42.55,29.785,AETNA [1000108],AETNA [100010801],,,76.8,,32.68,0.222255,85118.57664,percent of total billed charges,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-07,NDC,outpatient,10,ML,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,0.222255,85118.57664,percent of total billed charges,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-10,NDC,outpatient,10,ML,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,0.222255,85118.57664,percent of total billed charges,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,99999-0000-87,NDC,outpatient,100,ML,34.01,23.807,AETNA [1000108],AETNA [100010801],,,76.8,,26.12,0.222255,85118.57664,percent of total billed charges,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,AETNA [1000108],AETNA [100010801],,,76.8,,75.52,0.222255,85118.57664,percent of total billed charges,
DILTIAZEM 100 MG IN 100 ML NS BATCHED INFUSION,RX-4081050,CDM,S5000,HCPCS,250,RC,99999-0002-64,NDC,outpatient,100,ML,56.68,39.676,AETNA [1000108],AETNA [100010801],,,76.8,,43.53,0.222255,85118.57664,percent of total billed charges,
URSODIOL 50 MG/ML ORAL SUSPENSION,RX-4081064,CDM,S5000,HCPCS,259,RC,99999-0002-69,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BUPRENORPHINE-NALOXONE (SUBOXONE) SL FILM 8 MG-2 MG KIT,RX-4081171,CDM,S5000,HCPCS,259,RC,99999-0003-16,NDC,outpatient,1,UN,142.33,99.631,AETNA [1000108],AETNA [100010801],,,76.8,,109.31,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-05,NDC,outpatient,5,ML,19.63,13.741,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-15,NDC,outpatient,5,ML,19.63,13.741,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-11,NDC,outpatient,5,ML,17.92,12.544,AETNA [1000108],AETNA [100010801],,,76.8,,13.76,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-34,NDC,outpatient,5,ML,17.92,12.544,AETNA [1000108],AETNA [100010801],,,76.8,,13.76,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,63323-0208-05,NDC,outpatient,5,ML,7.41,5.187,AETNA [1000108],AETNA [100010801],,,76.8,,5.69,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,76329-3390-01,NDC,outpatient,5,ML,27.15,19.005,AETNA [1000108],AETNA [100010801],,,76.8,,20.85,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,AETNA [1000108],AETNA [100010801],,,76.8,,18.32,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,12.64,8.848,AETNA [1000108],AETNA [100010801],,,76.8,,9.71,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,12.64,8.848,AETNA [1000108],AETNA [100010801],,,76.8,,9.71,0.222255,85118.57664,percent of total billed charges,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 100 MG/100 ML IN NS PF PREMIX,RX-4081195,CDM,S5000,HCPCS,250,RC,99999-0003-26,NDC,outpatient,100,ML,312.37,218.659,AETNA [1000108],AETNA [100010801],,,76.8,,239.9,0.222255,85118.57664,percent of total billed charges,
PANTOPRAZOLE 80 MG/100 ML INFUSION PREMIX,RX-4081208,CDM,S5000,HCPCS,250,RC,99999-0000-77,NDC,outpatient,100,ML,36.56,25.592,AETNA [1000108],AETNA [100010801],,,76.8,,28.08,0.222255,85118.57664,percent of total billed charges,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-01,NDC,outpatient,200,ML,242.06,169.442,AETNA [1000108],AETNA [100010801],,,76.8,,185.9,0.222255,85118.57664,percent of total billed charges,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-10,NDC,outpatient,200,ML,242.06,169.442,AETNA [1000108],AETNA [100010801],,,76.8,,185.9,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 3 % IV ONCE,RX-4081432,CDM,S5000,HCPCS,250,RC,99999-0003-86,NDC,outpatient,100,ML,18.06,12.642,AETNA [1000108],AETNA [100010801],,,76.8,,13.87,0.222255,85118.57664,percent of total billed charges,
FAMOTIDINE IN NACL 20-0.9 MG/10 ML-% IV SOSY,RX-4081444,CDM,S5000,HCPCS,250,RC,99999-0003-96,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML IO SOLN WRAPPER,RX-4081458,CDM,S5000,HCPCS,250,RC,05047-4508-38,NDC,outpatient,0.4,ML,397.92,278.544,AETNA [1000108],AETNA [100010801],,,76.8,,305.6,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV *BATCHED*,RX-4081542,CDM,S5000,HCPCS,250,RC,99999-0004-35,NDC,outpatient,50,ML,157.29,110.103,AETNA [1000108],AETNA [100010801],,,76.8,,120.8,0.222255,85118.57664,percent of total billed charges,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.222255,85118.57664,percent of total billed charges,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,70092-1518-75,NDC,outpatient,100,ML,209.09,146.363,AETNA [1000108],AETNA [100010801],,,76.8,,160.58,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,99999-0004-53,NDC,outpatient,100,ML,48.85,34.195,AETNA [1000108],AETNA [100010801],,,76.8,,37.52,0.222255,85118.57664,percent of total billed charges,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,0.5,UN,2.9,2.03,AETNA [1000108],AETNA [100010801],,,76.8,,2.23,0.222255,85118.57664,percent of total billed charges,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,0.5,UN,1,0.7,AETNA [1000108],AETNA [100010801],,,76.8,,0.77,0.222255,85118.57664,percent of total billed charges,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,0.5,UN,4.12,2.884,AETNA [1000108],AETNA [100010801],,,76.8,,3.16,0.222255,85118.57664,percent of total billed charges,
METHADONE 10 MG TABLET DISCHARGE KIT,RX-4081610,CDM,S5000,HCPCS,259,RC,99999-0004-50,NDC,outpatient,1,UN,6.15,4.305,AETNA [1000108],AETNA [100010801],,,76.8,,4.72,0.222255,85118.57664,percent of total billed charges,
PRISMASATE K 4/CA 2.5 CRRT SOLUTION,RX-40840045,CDM,S5000,HCPCS,250,RC,SH408-4045-01,NDC,outpatient,5000,ML,188.44,131.908,AETNA [1000108],AETNA [100010801],,,76.8,,144.72,0.222255,85118.57664,percent of total billed charges,
PRISMASATE K 2/CA 0 CRRT SOLUTION,RX-40840046,CDM,S5000,HCPCS,250,RC,SH408-4046-01,NDC,outpatient,5000,ML,188.44,131.908,AETNA [1000108],AETNA [100010801],,,76.8,,144.72,0.222255,85118.57664,percent of total billed charges,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0011-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0012-66,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,63629-2364-01,NDC,outpatient,1,UN,6.03,4.221,AETNA [1000108],AETNA [100010801],,,76.8,,4.63,0.222255,85118.57664,percent of total billed charges,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,47335-0835-83,NDC,outpatient,1,UN,5.27,3.689,AETNA [1000108],AETNA [100010801],,,76.8,,4.05,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,S5000,HCPCS,259,RC,00597-0087-17,NDC,outpatient,12.9,GR,1940.98,1358.686,AETNA [1000108],AETNA [100010801],,,76.8,,1490.67,0.222255,85118.57664,percent of total billed charges,
ENTECAVIR 0.5 MG ORAL TABS,RX-41147,CDM,S5000,HCPCS,259,RC,00003-1611-12,NDC,outpatient,1,UN,197.48,138.236,AETNA [1000108],AETNA [100010801],,,76.8,,151.66,0.222255,85118.57664,percent of total billed charges,
ENTECAVIR 1 MG ORAL TABS,RX-41148,CDM,S5000,HCPCS,259,RC,65862-0842-30,NDC,outpatient,1,UN,8.95,6.265,AETNA [1000108],AETNA [100010801],,,76.8,,6.87,0.222255,85118.57664,percent of total billed charges,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-16,NDC,outpatient,1,UN,50.62,35.434,AETNA [1000108],AETNA [100010801],,,76.8,,38.88,0.222255,85118.57664,percent of total billed charges,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-11,NDC,outpatient,1,UN,21.37,14.959,AETNA [1000108],AETNA [100010801],,,76.8,,16.41,0.222255,85118.57664,percent of total billed charges,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-98,NDC,outpatient,1,UN,50.62,35.434,AETNA [1000108],AETNA [100010801],,,76.8,,38.88,0.222255,85118.57664,percent of total billed charges,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-47,NDC,outpatient,1,UN,21.37,14.959,AETNA [1000108],AETNA [100010801],,,76.8,,16.41,0.222255,85118.57664,percent of total billed charges,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,49483-0687-03,NDC,outpatient,1,UN,4.45,3.115,AETNA [1000108],AETNA [100010801],,,76.8,,3.42,0.222255,85118.57664,percent of total billed charges,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,65862-0936-30,NDC,outpatient,1,UN,5.24,3.668,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.222255,85118.57664,percent of total billed charges,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,52817-0830-04,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,99999-0002-52,NDC,outpatient,10,ML,6.37,4.459,AETNA [1000108],AETNA [100010801],,,76.8,,4.89,0.222255,85118.57664,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-05,NDC,outpatient,0.5,ML,58.03,40.621,AETNA [1000108],AETNA [100010801],,,76.8,,44.57,0.222255,85118.57664,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-01,NDC,outpatient,0.5,ML,58.03,40.621,AETNA [1000108],AETNA [100010801],,,76.8,,44.57,0.222255,85118.57664,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-02,NDC,outpatient,0.5,ML,64.31,45.017,AETNA [1000108],AETNA [100010801],,,76.8,,49.39,0.222255,85118.57664,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-00,NDC,outpatient,0.5,ML,58.19,40.733,AETNA [1000108],AETNA [100010801],,,76.8,,44.69,0.222255,85118.57664,percent of total billed charges,
OMEGA-3-ACID ETHYL ESTERS 1 G ORAL CAPS,RX-41822,CDM,S5000,HCPCS,259,RC,64380-0761-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,65162-0918-38,NDC,outpatient,35.44,GR,50,35,AETNA [1000108],AETNA [100010801],,,76.8,,38.4,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,64380-0789-32,NDC,outpatient,35.44,GR,61.67,43.169,AETNA [1000108],AETNA [100010801],,,76.8,,47.36,0.222255,85118.57664,percent of total billed charges,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,63739-0072-33,NDC,outpatient,1,UN,2.21,1.547,AETNA [1000108],AETNA [100010801],,,76.8,,1.7,0.222255,85118.57664,percent of total billed charges,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,00904-6671-04,NDC,outpatient,1,UN,2.21,1.547,AETNA [1000108],AETNA [100010801],,,76.8,,1.7,0.222255,85118.57664,percent of total billed charges,
METRONIDAZOLE 1 % EX GEL,RX-41899,CDM,S5000,HCPCS,259,RC,51672-4215-03,NDC,outpatient,60,GR,258.99,181.293,AETNA [1000108],AETNA [100010801],,,76.8,,198.9,0.222255,85118.57664,percent of total billed charges,
AVEENO SOOTHING BATH TREATMENT EX PACK,RX-41904,CDM,S5000,HCPCS,259,RC,08137-0036-40,NDC,outpatient,1,UN,2.74,1.918,AETNA [1000108],AETNA [100010801],,,76.8,,2.1,0.222255,85118.57664,percent of total billed charges,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-15,NDC,outpatient,1,UN,11.47,8.029,AETNA [1000108],AETNA [100010801],,,76.8,,8.81,0.222255,85118.57664,percent of total billed charges,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-11,NDC,outpatient,1,UN,11.47,8.029,AETNA [1000108],AETNA [100010801],,,76.8,,8.81,0.222255,85118.57664,percent of total billed charges,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,70010-0028-03,NDC,outpatient,1,UN,6.31,4.417,AETNA [1000108],AETNA [100010801],,,76.8,,4.85,0.222255,85118.57664,percent of total billed charges,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,99999-0003-12,NDC,outpatient,5,ML,5.06,3.542,AETNA [1000108],AETNA [100010801],,,76.8,,3.89,0.222255,85118.57664,percent of total billed charges,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,00054-0622-63,NDC,outpatient,5,ML,3.5,2.45,AETNA [1000108],AETNA [100010801],,,76.8,,2.69,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,50228-0350-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-01,NDC,outpatient,1,UN,1.96,1.372,AETNA [1000108],AETNA [100010801],,,76.8,,1.51,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-11,NDC,outpatient,1,UN,1.96,1.372,AETNA [1000108],AETNA [100010801],,,76.8,,1.51,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00071-1013-41,NDC,outpatient,1,UN,45.77,32.039,AETNA [1000108],AETNA [100010801],,,76.8,,35.15,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00904-6992-61,NDC,outpatient,1,UN,2.3,1.61,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,72205-0012-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-01,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-11,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00904-7000-61,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,62332-0121-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00071-1014-41,NDC,outpatient,1,UN,45.77,32.039,AETNA [1000108],AETNA [100010801],,,76.8,,35.15,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,62332-0122-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,00904-7001-61,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,69238-1313-09,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00904-7002-61,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00071-1016-41,NDC,outpatient,1,UN,45.77,32.039,AETNA [1000108],AETNA [100010801],,,76.8,,35.15,0.222255,85118.57664,percent of total billed charges,
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,S5000,HCPCS,250,RC,42023-0113-10,NDC,outpatient,20,ML,41.57,29.099,AETNA [1000108],AETNA [100010801],,,76.8,,31.93,0.222255,85118.57664,percent of total billed charges,
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,S5000,HCPCS,250,RC,42023-0115-10,NDC,outpatient,5,ML,53.45,37.415,AETNA [1000108],AETNA [100010801],,,76.8,,41.05,0.222255,85118.57664,percent of total billed charges,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-01,NDC,outpatient,10,ML,23.23,16.261,AETNA [1000108],AETNA [100010801],,,76.8,,17.84,0.222255,85118.57664,percent of total billed charges,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-10,NDC,outpatient,10,ML,23.23,16.261,AETNA [1000108],AETNA [100010801],,,76.8,,17.84,0.222255,85118.57664,percent of total billed charges,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-11,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-15,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,70756-0201-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-01,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,00781-1487-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-11,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,00054-0057-46,NDC,outpatient,60,ML,612.5,428.75,AETNA [1000108],AETNA [100010801],,,76.8,,470.4,0.222255,85118.57664,percent of total billed charges,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,99999-0004-03,NDC,outpatient,2.5,ML,25.53,17.871,AETNA [1000108],AETNA [100010801],,,76.8,,19.61,0.222255,85118.57664,percent of total billed charges,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-01,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-11,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,S5000,HCPCS,259,RC,76329-6300-05,NDC,outpatient,4,ML,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,0.222255,85118.57664,percent of total billed charges,
AMMONIA AROMATIC IN INHA,RX-439,CDM,S5000,HCPCS,259,RC,67777-0251-01,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00555-0484-02,NDC,outpatient,1,UN,5.35,3.745,AETNA [1000108],AETNA [100010801],,,76.8,,4.11,0.222255,85118.57664,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00054-8496-19,NDC,outpatient,1,UN,7.46,5.222,AETNA [1000108],AETNA [100010801],,,76.8,,5.73,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-01,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-20,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-01,NDC,outpatient,1,UN,1.54,1.078,AETNA [1000108],AETNA [100010801],,,76.8,,1.18,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-11,NDC,outpatient,1,UN,1.54,1.078,AETNA [1000108],AETNA [100010801],,,76.8,,1.18,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,00074-4552-11,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-01,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-11,NDC,outpatient,1,UN,1.67,1.169,AETNA [1000108],AETNA [100010801],,,76.8,,1.28,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-01,NDC,outpatient,1,UN,1.67,1.169,AETNA [1000108],AETNA [100010801],,,76.8,,1.28,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-20,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-20,NDC,outpatient,1,UN,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-01,NDC,outpatient,1,UN,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-11,NDC,outpatient,1,UN,2.04,1.428,AETNA [1000108],AETNA [100010801],,,76.8,,1.57,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-01,NDC,outpatient,1,UN,2.04,1.428,AETNA [1000108],AETNA [100010801],,,76.8,,1.57,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-20,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,00074-6624-11,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-20,NDC,outpatient,1,UN,3.14,2.198,AETNA [1000108],AETNA [100010801],,,76.8,,2.41,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-01,NDC,outpatient,1,UN,3.14,2.198,AETNA [1000108],AETNA [100010801],,,76.8,,2.41,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,60687-0530-01,NDC,outpatient,1,UN,2.51,1.757,AETNA [1000108],AETNA [100010801],,,76.8,,1.93,0.222255,85118.57664,percent of total billed charges,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,00074-7069-11,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00527-6004-80,NDC,outpatient,50,ML,75.88,53.116,AETNA [1000108],AETNA [100010801],,,76.8,,58.28,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00054-3505-47,NDC,outpatient,50,ML,107.03,74.921,AETNA [1000108],AETNA [100010801],,,76.8,,82.2,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,60432-0465-51,NDC,outpatient,50,ML,131.72,92.204,AETNA [1000108],AETNA [100010801],,,76.8,,101.16,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 0.5 % IJ SOLN,RX-4451,CDM,S5000,HCPCS,250,RC,63323-0484-57,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-17,NDC,outpatient,50,ML,8.23,5.761,AETNA [1000108],AETNA [100010801],,,76.8,,6.32,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-01,NDC,outpatient,20,ML,4.63,3.241,AETNA [1000108],AETNA [100010801],,,76.8,,3.56,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-16,NDC,outpatient,20,ML,4.63,3.241,AETNA [1000108],AETNA [100010801],,,76.8,,3.56,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-02,NDC,outpatient,50,ML,8.23,5.761,AETNA [1000108],AETNA [100010801],,,76.8,,6.32,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-01,NDC,outpatient,20,ML,5.14,3.598,AETNA [1000108],AETNA [100010801],,,76.8,,3.95,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-02,NDC,outpatient,2,ML,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-17,NDC,outpatient,10,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-16,NDC,outpatient,20,ML,5.14,3.598,AETNA [1000108],AETNA [100010801],,,76.8,,3.95,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0255-20,NDC,outpatient,20,ML,4.22,2.954,AETNA [1000108],AETNA [100010801],,,76.8,,3.24,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-02,NDC,outpatient,20,ML,18.2,12.74,AETNA [1000108],AETNA [100010801],,,76.8,,13.98,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0254-10,NDC,outpatient,10,ML,3.76,2.632,AETNA [1000108],AETNA [100010801],,,76.8,,2.89,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-01,NDC,outpatient,2,ML,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-01,NDC,outpatient,10,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-26,NDC,outpatient,20,ML,8.02,5.614,AETNA [1000108],AETNA [100010801],,,76.8,,6.16,0.222255,85118.57664,percent of total billed charges,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-27,NDC,outpatient,20,ML,18.2,12.74,AETNA [1000108],AETNA [100010801],,,76.8,,13.98,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,16714-0298-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,65862-0016-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,00093-2178-01,NDC,outpatient,1,UN,3.21,2.247,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.222255,85118.57664,percent of total billed charges,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,59762-1207-01,NDC,outpatient,1,UN,3.28,2.296,AETNA [1000108],AETNA [100010801],,,76.8,,2.52,0.222255,85118.57664,percent of total billed charges,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,51862-0321-01,NDC,outpatient,1,UN,3.45,2.415,AETNA [1000108],AETNA [100010801],,,76.8,,2.65,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN 500 MG ORAL CAPS,RX-451,CDM,S5000,HCPCS,259,RC,16714-0299-03,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LITHIUM CARBONATE 150 MG ORAL CAPS,RX-4528,CDM,S5000,HCPCS,259,RC,00054-8526-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,31722-0545-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,00054-8527-25,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00093-4155-79,NDC,outpatient,80,ML,14.6,10.22,AETNA [1000108],AETNA [100010801],,,76.8,,11.21,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,99999-0002-83,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00143-9889-15,NDC,outpatient,150,ML,20.7,14.49,AETNA [1000108],AETNA [100010801],,,76.8,,15.9,0.222255,85118.57664,percent of total billed charges,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-01,NDC,outpatient,1,UN,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-11,NDC,outpatient,1,UN,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-01,NDC,outpatient,1,UN,3,2.1,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,85118.57664,percent of total billed charges,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-20,NDC,outpatient,1,UN,3,2.1,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00054-3532-44,NDC,outpatient,30,ML,100.26,70.182,AETNA [1000108],AETNA [100010801],,,76.8,,77,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00121-0770-01,NDC,outpatient,30,ML,33.11,23.177,AETNA [1000108],AETNA [100010801],,,76.8,,25.43,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,99999-0001-38,NDC,outpatient,1,ML,3.55,2.485,AETNA [1000108],AETNA [100010801],,,76.8,,2.73,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,69315-0904-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,13107-0083-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00093-3425-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00093-3426-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00904-6008-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LOXAPINE SUCCINATE 25 MG ORAL CAPS,RX-4600,CDM,S5000,HCPCS,259,RC,00591-0371-01,NDC,outpatient,1,UN,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,
LOXAPINE SUCCINATE 5 MG ORAL CAPS,RX-4601,CDM,S5000,HCPCS,259,RC,00591-0369-01,NDC,outpatient,1,UN,1.31,0.917,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,
MAGNESIUM CITRATE 1.745 GM/30ML ORAL SOLN,RX-4711,CDM,S5000,HCPCS,259,RC,70677-1111-01,NDC,outpatient,296,ML,7.91,5.537,AETNA [1000108],AETNA [100010801],,,76.8,,6.07,0.222255,85118.57664,percent of total billed charges,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-03,NDC,outpatient,500,ML,93.88,65.716,AETNA [1000108],AETNA [100010801],,,76.8,,72.1,0.222255,85118.57664,percent of total billed charges,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-02,NDC,outpatient,250,ML,79.42,55.594,AETNA [1000108],AETNA [100010801],,,76.8,,60.99,0.222255,85118.57664,percent of total billed charges,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-13,NDC,outpatient,500,ML,93.88,65.716,AETNA [1000108],AETNA [100010801],,,76.8,,72.1,0.222255,85118.57664,percent of total billed charges,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-03,NDC,outpatient,500,ML,80.53,56.371,AETNA [1000108],AETNA [100010801],,,76.8,,61.85,0.222255,85118.57664,percent of total billed charges,
MEDROXYPROGESTERONE ACETATE 10 MG ORAL TABS,RX-4854,CDM,S5000,HCPCS,259,RC,00555-0779-02,NDC,outpatient,1,UN,1.07,0.749,AETNA [1000108],AETNA [100010801],,,76.8,,0.82,0.222255,85118.57664,percent of total billed charges,
MEDROXYPROGESTERONE ACETATE 2.5 MG ORAL TABS,RX-4855,CDM,S5000,HCPCS,259,RC,00555-0872-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-23,NDC,outpatient,1,UN,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00054-0710-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-62,NDC,outpatient,1,UN,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-23,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-62,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,
METHAZOLAMIDE 50 MG ORAL TABS,RX-4962,CDM,S5000,HCPCS,259,RC,00574-0791-01,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,76385-0123-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,00904-7057-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,31722-0533-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-21,NDC,outpatient,1,UN,5.13,3.591,AETNA [1000108],AETNA [100010801],,,76.8,,3.94,0.222255,85118.57664,percent of total billed charges,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,00406-1144-01,NDC,outpatient,1,UN,1.43,1.001,AETNA [1000108],AETNA [100010801],,,76.8,,1.1,0.222255,85118.57664,percent of total billed charges,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-11,NDC,outpatient,1,UN,5.13,3.591,AETNA [1000108],AETNA [100010801],,,76.8,,3.94,0.222255,85118.57664,percent of total billed charges,
METHYLPREDNISOLONE 16 MG ORAL TABS,RX-4992,CDM,S5000,HCPCS,259,RC,59762-0050-01,NDC,outpatient,1,UN,8.54,5.978,AETNA [1000108],AETNA [100010801],,,76.8,,6.56,0.222255,85118.57664,percent of total billed charges,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-11,NDC,outpatient,1,UN,4.95,3.465,AETNA [1000108],AETNA [100010801],,,76.8,,3.8,0.222255,85118.57664,percent of total billed charges,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,00904-6914-61,NDC,outpatient,1,UN,4.37,3.059,AETNA [1000108],AETNA [100010801],,,76.8,,3.36,0.222255,85118.57664,percent of total billed charges,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-01,NDC,outpatient,1,UN,4.95,3.465,AETNA [1000108],AETNA [100010801],,,76.8,,3.8,0.222255,85118.57664,percent of total billed charges,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-11,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-01,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
METRONIDAZOLE 250 MG ORAL TABS,RX-5015,CDM,S5000,HCPCS,259,RC,00904-7156-61,NDC,outpatient,1,UN,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-01,NDC,outpatient,1,UN,2.17,1.519,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-11,NDC,outpatient,1,UN,2.17,1.519,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,29300-0227-01,NDC,outpatient,1,UN,1.76,1.232,AETNA [1000108],AETNA [100010801],,,76.8,,1.35,0.222255,85118.57664,percent of total billed charges,
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,S5000,HCPCS,259,RC,61269-0735-14,NDC,outpatient,14,GR,7.54,5.278,AETNA [1000108],AETNA [100010801],,,76.8,,5.79,0.222255,85118.57664,percent of total billed charges,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,48433-0202-30,NDC,outpatient,30,ML,5.08,3.556,AETNA [1000108],AETNA [100010801],,,76.8,,3.9,0.222255,85118.57664,percent of total billed charges,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,99999-0002-15,NDC,outpatient,30,ML,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,
MINOCYCLINE HCL 50 MG ORAL CAPS,RX-5111,CDM,S5000,HCPCS,259,RC,00591-5694-60,NDC,outpatient,1,UN,1.26,0.882,AETNA [1000108],AETNA [100010801],,,76.8,,0.97,0.222255,85118.57664,percent of total billed charges,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-01,NDC,outpatient,1,UN,2.48,1.736,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-11,NDC,outpatient,1,UN,2.48,1.736,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,00591-5642-01,NDC,outpatient,1,UN,1.01,0.707,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-01,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-11,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-05,NDC,outpatient,5,ML,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-94,NDC,outpatient,5,ML,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-62,NDC,outpatient,5,ML,4.7,3.29,AETNA [1000108],AETNA [100010801],,,76.8,,3.61,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00054-0237-49,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],,,76.8,,28.71,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-59,NDC,outpatient,5,ML,4.7,3.29,AETNA [1000108],AETNA [100010801],,,76.8,,3.61,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,99999-0002-19,NDC,outpatient,5,ML,2.14,1.498,AETNA [1000108],AETNA [100010801],,,76.8,,1.64,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-25,NDC,outpatient,1,UN,2.1,1.47,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-24,NDC,outpatient,1,UN,3.2,2.24,AETNA [1000108],AETNA [100010801],,,76.8,,2.46,0.222255,85118.57664,percent of total billed charges,
MORPHINE SULFATE 10 MG RE SUPP,RX-5180,CDM,S5000,HCPCS,259,RC,00574-7112-12,NDC,outpatient,1,UN,19.66,13.762,AETNA [1000108],AETNA [100010801],,,76.8,,15.1,0.222255,85118.57664,percent of total billed charges,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-95,NDC,outpatient,1,UN,11.38,7.966,AETNA [1000108],AETNA [100010801],,,76.8,,8.74,0.222255,85118.57664,percent of total billed charges,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-25,NDC,outpatient,1,UN,11.38,7.966,AETNA [1000108],AETNA [100010801],,,76.8,,8.74,0.222255,85118.57664,percent of total billed charges,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,00904-7071-07,NDC,outpatient,1,UN,9.11,6.377,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.222255,85118.57664,percent of total billed charges,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,69097-0868-07,NDC,outpatient,1,UN,1.13,0.791,AETNA [1000108],AETNA [100010801],,,76.8,,0.87,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,65162-0188-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,65162-0189-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,63739-0403-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65162-0190-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65862-0522-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-05,NDC,outpatient,1,UN,3.09,2.163,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-07,NDC,outpatient,1,UN,3.09,2.163,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,S5000,HCPCS,259,RC,24208-0790-62,NDC,outpatient,10,ML,150.86,105.602,AETNA [1000108],AETNA [100010801],,,76.8,,115.86,0.222255,85118.57664,percent of total billed charges,
NIACIN 100 MG ORAL TABS,RX-5539,CDM,S5000,HCPCS,259,RC,80681-0057-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NIFEDIPINE 10 MG ORAL CAPS,RX-5558,CDM,S5000,HCPCS,259,RC,23155-0194-01,NDC,outpatient,1,UN,1.98,1.386,AETNA [1000108],AETNA [100010801],,,76.8,,1.52,0.222255,85118.57664,percent of total billed charges,
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAPS,RX-5595,CDM,S5000,HCPCS,259,RC,57664-0232-88,NDC,outpatient,1,UN,3.41,2.387,AETNA [1000108],AETNA [100010801],,,76.8,,2.62,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,68462-0638-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,00071-0417-24,NDC,outpatient,1,UN,3.05,2.135,AETNA [1000108],AETNA [100010801],,,76.8,,2.34,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,72888-0138-01,NDC,outpatient,1,UN,1.43,1.001,AETNA [1000108],AETNA [100010801],,,76.8,,1.1,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-25,NDC,outpatient,0.75,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-11,NDC,outpatient,0.75,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-35,NDC,outpatient,0.75,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-45,NDC,outpatient,0.75,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,S5000,HCPCS,259,RC,00281-0326-08,NDC,outpatient,1,GR,9.96,6.972,AETNA [1000108],AETNA [100010801],,,76.8,,7.65,0.222255,85118.57664,percent of total billed charges,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-01,NDC,outpatient,1,UN,1.89,1.323,AETNA [1000108],AETNA [100010801],,,76.8,,1.45,0.222255,85118.57664,percent of total billed charges,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-11,NDC,outpatient,1,UN,1.89,1.323,AETNA [1000108],AETNA [100010801],,,76.8,,1.45,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,00713-0678-15,NDC,outpatient,15,GR,53.4,37.38,AETNA [1000108],AETNA [100010801],,,76.8,,41.01,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,45802-0059-35,NDC,outpatient,15,GR,17.03,11.921,AETNA [1000108],AETNA [100010801],,,76.8,,13.08,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,51672-1289-01,NDC,outpatient,15,GR,18.83,13.181,AETNA [1000108],AETNA [100010801],,,76.8,,14.46,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,45802-0048-35,NDC,outpatient,15,GR,13.29,9.303,AETNA [1000108],AETNA [100010801],,,76.8,,10.21,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,00472-0166-15,NDC,outpatient,15,GR,61.35,42.945,AETNA [1000108],AETNA [100010801],,,76.8,,47.12,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,99999-0003-91,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-10,NDC,outpatient,5,ML,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-70,NDC,outpatient,5,ML,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-00,NDC,outpatient,5,ML,4.74,3.318,AETNA [1000108],AETNA [100010801],,,76.8,,3.64,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-1045-16,NDC,outpatient,5,ML,4.21,2.947,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-05,NDC,outpatient,5,ML,4.74,3.318,AETNA [1000108],AETNA [100010801],,,76.8,,3.64,0.222255,85118.57664,percent of total billed charges,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,S5000,HCPCS,259,RC,51672-1263-01,NDC,outpatient,15,GR,15.02,10.514,AETNA [1000108],AETNA [100010801],,,76.8,,11.54,0.222255,85118.57664,percent of total billed charges,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,S5000,HCPCS,259,RC,51672-1272-01,NDC,outpatient,15,GR,22.37,15.659,AETNA [1000108],AETNA [100010801],,,76.8,,17.18,0.222255,85118.57664,percent of total billed charges,
ORA-PLUS ORAL LIQD,RX-5851,CDM,S5000,HCPCS,259,RC,00574-0303-16,NDC,outpatient,473,ML,130.96,91.672,AETNA [1000108],AETNA [100010801],,,76.8,,100.58,0.222255,85118.57664,percent of total billed charges,
ORA-SWEET SF ORAL SYRP,RX-5853,CDM,S5000,HCPCS,259,RC,00574-0302-16,NDC,outpatient,473,ML,130.96,91.672,AETNA [1000108],AETNA [100010801],,,76.8,,100.58,0.222255,85118.57664,percent of total billed charges,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,00228-2067-10,NDC,outpatient,1,UN,3.24,2.268,AETNA [1000108],AETNA [100010801],,,76.8,,2.49,0.222255,85118.57664,percent of total billed charges,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-01,NDC,outpatient,1,UN,8.63,6.041,AETNA [1000108],AETNA [100010801],,,76.8,,6.63,0.222255,85118.57664,percent of total billed charges,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-11,NDC,outpatient,1,UN,8.63,6.041,AETNA [1000108],AETNA [100010801],,,76.8,,6.63,0.222255,85118.57664,percent of total billed charges,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-11,NDC,outpatient,1,UN,9.09,6.363,AETNA [1000108],AETNA [100010801],,,76.8,,6.98,0.222255,85118.57664,percent of total billed charges,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-01,NDC,outpatient,1,UN,9.09,6.363,AETNA [1000108],AETNA [100010801],,,76.8,,6.98,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-11,NDC,outpatient,1,UN,1.85,1.295,AETNA [1000108],AETNA [100010801],,,76.8,,1.42,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-01,NDC,outpatient,1,UN,1.85,1.295,AETNA [1000108],AETNA [100010801],,,76.8,,1.42,0.222255,85118.57664,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,00904-7027-61,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-62,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-23,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,00517-4002-25,NDC,outpatient,2,ML,103.84,72.688,AETNA [1000108],AETNA [100010801],,,76.8,,79.75,0.222255,85118.57664,percent of total billed charges,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-01,NDC,outpatient,2,ML,69.91,48.937,AETNA [1000108],AETNA [100010801],,,76.8,,53.69,0.222255,85118.57664,percent of total billed charges,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-05,NDC,outpatient,2,ML,78.96,55.272,AETNA [1000108],AETNA [100010801],,,76.8,,60.64,0.222255,85118.57664,percent of total billed charges,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-10,NDC,outpatient,2,ML,69.91,48.937,AETNA [1000108],AETNA [100010801],,,76.8,,53.69,0.222255,85118.57664,percent of total billed charges,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-07,NDC,outpatient,2,ML,78.96,55.272,AETNA [1000108],AETNA [100010801],,,76.8,,60.64,0.222255,85118.57664,percent of total billed charges,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-95,NDC,outpatient,1,UN,142.02,99.414,AETNA [1000108],AETNA [100010801],,,76.8,,109.07,0.222255,85118.57664,percent of total billed charges,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-94,NDC,outpatient,1,UN,142.02,99.414,AETNA [1000108],AETNA [100010801],,,76.8,,109.07,0.222255,85118.57664,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,00093-4127-73,NDC,outpatient,100,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,99999-0002-88,NDC,outpatient,10,ML,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG ORAL TABS,RX-6092,CDM,S5000,HCPCS,259,RC,57237-0040-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00143-9836-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00093-1174-01,NDC,outpatient,1,UN,1.67,1.169,AETNA [1000108],AETNA [100010801],,,76.8,,1.28,0.222255,85118.57664,percent of total billed charges,
PERPHENAZINE 2 MG ORAL TABS,RX-6157,CDM,S5000,HCPCS,259,RC,00904-6599-61,NDC,outpatient,1,UN,2.75,1.925,AETNA [1000108],AETNA [100010801],,,76.8,,2.11,0.222255,85118.57664,percent of total billed charges,
PERPHENAZINE 8 MG ORAL TABS,RX-6159,CDM,S5000,HCPCS,259,RC,00904-6601-61,NDC,outpatient,1,UN,5.02,3.514,AETNA [1000108],AETNA [100010801],,,76.8,,3.86,0.222255,85118.57664,percent of total billed charges,
PHENAZOPYRIDINE HCL 100 MG ORAL TABS,RX-6193,CDM,S5000,HCPCS,259,RC,65162-0681-10,NDC,outpatient,1,UN,1.61,1.127,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-05,NDC,outpatient,5,ML,7.01,4.907,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,0.222255,85118.57664,percent of total billed charges,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,13517-0107-16,NDC,outpatient,473,ML,307.31,215.117,AETNA [1000108],AETNA [100010801],,,76.8,,236.01,0.222255,85118.57664,percent of total billed charges,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,16571-0675-16,NDC,outpatient,473,ML,82.09,57.463,AETNA [1000108],AETNA [100010801],,,76.8,,63.05,0.222255,85118.57664,percent of total billed charges,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,99999-0002-30,NDC,outpatient,5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-50,NDC,outpatient,5,ML,7.01,4.907,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,0.222255,85118.57664,percent of total billed charges,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,54932-0501-81,NDC,outpatient,473,ML,75.78,53.046,AETNA [1000108],AETNA [100010801],,,76.8,,58.2,0.222255,85118.57664,percent of total billed charges,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,00904-6575-61,NDC,outpatient,1,UN,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,16571-0673-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,S5000,HCPCS,259,RC,00225-0800-47,NDC,outpatient,15,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,S5000,HCPCS,259,RC,00225-0805-47,NDC,outpatient,15,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,S5000,HCPCS,259,RC,00225-0810-47,NDC,outpatient,15,ML,15.09,10.563,AETNA [1000108],AETNA [100010801],,,76.8,,11.59,0.222255,85118.57664,percent of total billed charges,
PHENYLEPHRINE HCL 2.5 % OP SOLN,RX-6246,CDM,S5000,HCPCS,259,RC,70756-0629-25,NDC,outpatient,2,ML,146.94,102.858,AETNA [1000108],AETNA [100010801],,,76.8,,112.85,0.222255,85118.57664,percent of total billed charges,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-66,NDC,outpatient,4,ML,13.48,9.436,AETNA [1000108],AETNA [100010801],,,76.8,,10.35,0.222255,85118.57664,percent of total billed charges,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-62,NDC,outpatient,4,ML,13.48,9.436,AETNA [1000108],AETNA [100010801],,,76.8,,10.35,0.222255,85118.57664,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,57664-0808-88,NDC,outpatient,1,UN,1.19,0.833,AETNA [1000108],AETNA [100010801],,,76.8,,0.91,0.222255,85118.57664,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,65862-0692-01,NDC,outpatient,1,UN,1.74,1.218,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,S5000,HCPCS,259,RC,61314-0203-15,NDC,outpatient,15,ML,342.03,239.421,AETNA [1000108],AETNA [100010801],,,76.8,,262.68,0.222255,85118.57664,percent of total billed charges,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,70069-0191-01,NDC,outpatient,15,ML,140.98,98.686,AETNA [1000108],AETNA [100010801],,,76.8,,108.27,0.222255,85118.57664,percent of total billed charges,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,61314-0204-15,NDC,outpatient,15,ML,351.44,246.008,AETNA [1000108],AETNA [100010801],,,76.8,,269.91,0.222255,85118.57664,percent of total billed charges,
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,S5000,HCPCS,259,RC,61314-0206-15,NDC,outpatient,15,ML,326.81,228.767,AETNA [1000108],AETNA [100010801],,,76.8,,250.99,0.222255,85118.57664,percent of total billed charges,
PIROXICAM 10 MG ORAL CAPS,RX-6310,CDM,S5000,HCPCS,259,RC,42571-0176-01,NDC,outpatient,1,UN,3.12,2.184,AETNA [1000108],AETNA [100010801],,,76.8,,2.4,0.222255,85118.57664,percent of total billed charges,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,00087-0402-03,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,99999-0001-68,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,S5000,HCPCS,250,RC,55150-0234-10,NDC,outpatient,1,UN,16.13,11.291,AETNA [1000108],AETNA [100010801],,,76.8,,12.39,0.222255,85118.57664,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-11,NDC,outpatient,20,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-01,NDC,outpatient,20,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,51754-2001-04,NDC,outpatient,20,ML,18.07,12.649,AETNA [1000108],AETNA [100010801],,,76.8,,13.88,0.222255,85118.57664,percent of total billed charges,
POVIDONE-IODINE 10 % EX SOLN,RX-6458,CDM,S5000,HCPCS,259,RC,52380-1905-00,NDC,outpatient,59,ML,4.73,3.311,AETNA [1000108],AETNA [100010801],,,76.8,,3.63,0.222255,85118.57664,percent of total billed charges,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-01,NDC,outpatient,1,UN,6.21,4.347,AETNA [1000108],AETNA [100010801],,,76.8,,4.77,0.222255,85118.57664,percent of total billed charges,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-20,NDC,outpatient,1,UN,6.21,4.347,AETNA [1000108],AETNA [100010801],,,76.8,,4.77,0.222255,85118.57664,percent of total billed charges,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-01,NDC,outpatient,1,UN,5.34,3.738,AETNA [1000108],AETNA [100010801],,,76.8,,4.1,0.222255,85118.57664,percent of total billed charges,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-11,NDC,outpatient,1,UN,5.34,3.738,AETNA [1000108],AETNA [100010801],,,76.8,,4.1,0.222255,85118.57664,percent of total billed charges,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-20,NDC,outpatient,1,UN,14.76,10.332,AETNA [1000108],AETNA [100010801],,,76.8,,11.34,0.222255,85118.57664,percent of total billed charges,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-01,NDC,outpatient,1,UN,14.76,10.332,AETNA [1000108],AETNA [100010801],,,76.8,,11.34,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,61314-0637-05,NDC,outpatient,5,ML,113.48,79.436,AETNA [1000108],AETNA [100010801],,,76.8,,87.15,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,11980-0180-05,NDC,outpatient,5,ML,534.23,373.961,AETNA [1000108],AETNA [100010801],,,76.8,,410.29,0.222255,85118.57664,percent of total billed charges,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,60758-0119-05,NDC,outpatient,5,ML,106.58,74.606,AETNA [1000108],AETNA [100010801],,,76.8,,81.85,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-4741-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-8739-25,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,59651-0484-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00054-0017-20,NDC,outpatient,1,UN,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00603-5338-21,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00904-6923-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-4742-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-8740-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,59746-0175-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00054-0018-20,NDC,outpatient,1,UN,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00904-7127-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,64380-0785-07,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,00054-8724-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-20,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-25,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,10135-0779-01,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,59651-0489-01,NDC,outpatient,1,UN,1.61,1.127,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,
ASCORBIC ACID 500 MG/ML IJ SOLN,RX-654,CDM,S5000,HCPCS,250,RC,67157-0101-51,NDC,outpatient,50,ML,1099.15,769.405,AETNA [1000108],AETNA [100010801],,,76.8,,844.15,0.222255,85118.57664,percent of total billed charges,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-15,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-11,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
PROBENECID 500 MG ORAL TABS,RX-6561,CDM,S5000,HCPCS,259,RC,00591-5347-01,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,27808-0065-02,NDC,outpatient,2.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,99999-0002-39,NDC,outpatient,5,ML,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,61314-0016-01,NDC,outpatient,15,ML,111.21,77.847,AETNA [1000108],AETNA [100010801],,,76.8,,85.41,0.222255,85118.57664,percent of total billed charges,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,24208-0730-06,NDC,outpatient,15,ML,110.61,77.427,AETNA [1000108],AETNA [100010801],,,76.8,,84.95,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00054-3727-63,NDC,outpatient,500,ML,209.15,146.405,AETNA [1000108],AETNA [100010801],,,76.8,,160.63,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-05,NDC,outpatient,5,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-40,NDC,outpatient,5,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,69238-2077-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,00378-0182-01,NDC,outpatient,1,UN,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-11,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-01,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,00603-5484-21,NDC,outpatient,1,UN,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,00228-2348-10,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,67253-0651-10,NDC,outpatient,1,UN,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-6990-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-5053-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,10135-0735-60,NDC,outpatient,1,UN,15.09,10.563,AETNA [1000108],AETNA [100010801],,,76.8,,11.59,0.222255,85118.57664,percent of total billed charges,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,33342-0447-11,NDC,outpatient,1,UN,19.28,13.496,AETNA [1000108],AETNA [100010801],,,76.8,,14.81,0.222255,85118.57664,percent of total billed charges,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,70954-0484-10,NDC,outpatient,1,UN,17.43,12.201,AETNA [1000108],AETNA [100010801],,,76.8,,13.39,0.222255,85118.57664,percent of total billed charges,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
QUININE SULFATE 324 MG ORAL CAPS,RX-6781,CDM,S5000,HCPCS,259,RC,50742-0238-30,NDC,outpatient,1,UN,2.82,1.974,AETNA [1000108],AETNA [100010801],,,76.8,,2.17,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,63739-0434-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,66553-0002-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-80,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,57896-0901-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,66553-0001-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 325 MG ORAL TBEC,RX-685,CDM,S5000,HCPCS,259,RC,57896-0921-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00536-1234-41,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,63739-0212-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00904-6783-70,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ASPIRIN 300 MG RE SUPP,RX-693,CDM,S5000,HCPCS,259,RC,00574-7034-12,NDC,outpatient,1,UN,4.58,3.206,AETNA [1000108],AETNA [100010801],,,76.8,,3.52,0.222255,85118.57664,percent of total billed charges,
INSULIN DETEMIR 100 UNIT/ML SC SOLN,RX-70261,CDM,S5000,HCPCS,259,RC,00169-3687-12,NDC,outpatient,10,ML,388.27,271.789,AETNA [1000108],AETNA [100010801],,,76.8,,298.19,0.222255,85118.57664,percent of total billed charges,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-99,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,00904-3865-75,NDC,outpatient,44,ML,3.33,2.331,AETNA [1000108],AETNA [100010801],,,76.8,,2.56,0.222255,85118.57664,percent of total billed charges,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,49348-0356-25,NDC,outpatient,44,ML,5.88,4.116,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,0.222255,85118.57664,percent of total billed charges,
TRAMADOL HCL ER 200 MG ORAL TB24,RX-70353,CDM,S5000,HCPCS,259,RC,68180-0698-06,NDC,outpatient,1,UN,19.84,13.888,AETNA [1000108],AETNA [100010801],,,76.8,,15.24,0.222255,85118.57664,percent of total billed charges,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-11,NDC,outpatient,1,UN,5.07,3.549,AETNA [1000108],AETNA [100010801],,,76.8,,3.89,0.222255,85118.57664,percent of total billed charges,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-15,NDC,outpatient,1,UN,5.07,3.549,AETNA [1000108],AETNA [100010801],,,76.8,,3.89,0.222255,85118.57664,percent of total billed charges,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-11,NDC,outpatient,1,UN,5.08,3.556,AETNA [1000108],AETNA [100010801],,,76.8,,3.9,0.222255,85118.57664,percent of total billed charges,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-21,NDC,outpatient,1,UN,5.08,3.556,AETNA [1000108],AETNA [100010801],,,76.8,,3.9,0.222255,85118.57664,percent of total billed charges,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,68462-0319-60,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
LUBIPROSTONE 24 MCG ORAL CAPS,RX-70472,CDM,S5000,HCPCS,259,RC,00254-3029-02,NDC,outpatient,1,UN,4.45,3.115,AETNA [1000108],AETNA [100010801],,,76.8,,3.42,0.222255,85118.57664,percent of total billed charges,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00536-1183-99,NDC,outpatient,9.9,ML,45.6,31.92,AETNA [1000108],AETNA [100010801],,,76.8,,35.02,0.222255,85118.57664,percent of total billed charges,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00054-3270-99,NDC,outpatient,16,GR,32.12,22.484,AETNA [1000108],AETNA [100010801],,,76.8,,24.67,0.222255,85118.57664,percent of total billed charges,
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,S5000,HCPCS,259,RC,00002-7511-01,NDC,outpatient,10,ML,211.82,148.274,AETNA [1000108],AETNA [100010801],,,76.8,,162.68,0.222255,85118.57664,percent of total billed charges,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,61570-0131-55,NDC,outpatient,50,GR,30.49,21.343,AETNA [1000108],AETNA [100010801],,,76.8,,23.42,0.222255,85118.57664,percent of total billed charges,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-40,NDC,outpatient,400,GR,153.08,107.156,AETNA [1000108],AETNA [100010801],,,76.8,,117.57,0.222255,85118.57664,percent of total billed charges,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-50,NDC,outpatient,50,GR,55.18,38.626,AETNA [1000108],AETNA [100010801],,,76.8,,42.38,0.222255,85118.57664,percent of total billed charges,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,69618-0033-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,00904-7206-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,49348-0188-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,00536-1303-75,NDC,outpatient,0.3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,49348-0740-27,NDC,outpatient,0.6,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,99999-0003-45,NDC,outpatient,0.6,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-73,NDC,outpatient,20,ML,14.91,10.437,AETNA [1000108],AETNA [100010801],,,76.8,,11.45,0.222255,85118.57664,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-83,NDC,outpatient,20,ML,14.91,10.437,AETNA [1000108],AETNA [100010801],,,76.8,,11.45,0.222255,85118.57664,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-04,NDC,outpatient,100,ML,36.05,25.235,AETNA [1000108],AETNA [100010801],,,76.8,,27.69,0.222255,85118.57664,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-00,NDC,outpatient,100,ML,36.05,25.235,AETNA [1000108],AETNA [100010801],,,76.8,,27.69,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-02,NDC,outpatient,5,ML,19.45,13.615,AETNA [1000108],AETNA [100010801],,,76.8,,14.94,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-14,NDC,outpatient,10,ML,57.94,40.558,AETNA [1000108],AETNA [100010801],,,76.8,,44.5,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-24,NDC,outpatient,10,ML,57.94,40.558,AETNA [1000108],AETNA [100010801],,,76.8,,44.5,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-12,NDC,outpatient,5,ML,19.45,13.615,AETNA [1000108],AETNA [100010801],,,76.8,,14.94,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,63323-0083-05,NDC,outpatient,5,ML,33.6,23.52,AETNA [1000108],AETNA [100010801],,,76.8,,25.8,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-14,NDC,outpatient,50,ML,85.67,59.969,AETNA [1000108],AETNA [100010801],,,76.8,,65.79,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-24,NDC,outpatient,50,ML,85.67,59.969,AETNA [1000108],AETNA [100010801],,,76.8,,65.79,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-24,NDC,outpatient,10,ML,71.78,50.246,AETNA [1000108],AETNA [100010801],,,76.8,,55.13,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-22,NDC,outpatient,50,ML,35.83,25.081,AETNA [1000108],AETNA [100010801],,,76.8,,27.52,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-24,NDC,outpatient,50,ML,54.74,38.318,AETNA [1000108],AETNA [100010801],,,76.8,,42.04,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,69374-0214-50,NDC,outpatient,50,ML,48.95,34.265,AETNA [1000108],AETNA [100010801],,,76.8,,37.59,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-14,NDC,outpatient,50,ML,35.83,25.081,AETNA [1000108],AETNA [100010801],,,76.8,,27.52,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-04,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,76329-3352-01,NDC,outpatient,50,ML,66.31,46.417,AETNA [1000108],AETNA [100010801],,,76.8,,50.93,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-14,NDC,outpatient,10,ML,71.78,50.246,AETNA [1000108],AETNA [100010801],,,76.8,,55.13,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-14,NDC,outpatient,50,ML,54.74,38.318,AETNA [1000108],AETNA [100010801],,,76.8,,42.04,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-01,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,63323-0089-50,NDC,outpatient,50,ML,24.7,17.29,AETNA [1000108],AETNA [100010801],,,76.8,,18.97,0.222255,85118.57664,percent of total billed charges,
SODIUM BICARBONATE 650 MG ORAL TABS,RX-7313,CDM,S5000,HCPCS,259,RC,66553-0008-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,99999-0004-11,NDC,outpatient,250,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,00338-0054-03,NDC,outpatient,500,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-61,NDC,outpatient,100,ML,55.63,38.941,AETNA [1000108],AETNA [100010801],,,76.8,,42.72,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-02,NDC,outpatient,100,ML,55.63,38.941,AETNA [1000108],AETNA [100010801],,,76.8,,42.72,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-03,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,76204-0300-03,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-33,NDC,outpatient,3,ML,1.13,0.791,AETNA [1000108],AETNA [100010801],,,76.8,,0.87,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,00487-9003-30,NDC,outpatient,4,ML,2.44,1.708,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,50190-0142-63,NDC,outpatient,4,ML,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-25,NDC,outpatient,1,UN,1.03,0.721,AETNA [1000108],AETNA [100010801],,,76.8,,0.79,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,00223-1760-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-10,NDC,outpatient,1,UN,1.03,0.721,AETNA [1000108],AETNA [100010801],,,76.8,,0.79,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,S5000,HCPCS,259,RC,24208-0385-55,NDC,outpatient,3.5,GR,68.8,48.16,AETNA [1000108],AETNA [100010801],,,76.8,,52.84,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,S5000,HCPCS,259,RC,00536-1254-94,NDC,outpatient,15,ML,15.76,11.032,AETNA [1000108],AETNA [100010801],,,76.8,,12.1,0.222255,85118.57664,percent of total billed charges,
SODIUM HYPOCHLORITE 5 % SOLN,RX-7343,CDM,S5000,HCPCS,259,RC,SH000-4343-01,NDC,outpatient,4000,ML,17.8,12.46,AETNA [1000108],AETNA [100010801],,,76.8,,13.67,0.222255,85118.57664,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE ORAL POWD,RX-7356,CDM,S5000,HCPCS,259,RC,11534-0166-15,NDC,outpatient,15,GR,55.61,38.927,AETNA [1000108],AETNA [100010801],,,76.8,,42.71,0.222255,85118.57664,percent of total billed charges,
SULFACETAMIDE SODIUM 10 % OP SOLN,RX-7359,CDM,S5000,HCPCS,259,RC,24208-0670-04,NDC,outpatient,15,ML,213.67,149.569,AETNA [1000108],AETNA [100010801],,,76.8,,164.1,0.222255,85118.57664,percent of total billed charges,
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,S5000,HCPCS,259,RC,60219-1749-03,NDC,outpatient,5,ML,103.02,72.114,AETNA [1000108],AETNA [100010801],,,76.8,,79.12,0.222255,85118.57664,percent of total billed charges,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,00904-6927-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,63629-1061-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,AETNA [1000108],AETNA [100010801],,,76.8,,2.76,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-24,NDC,outpatient,50,ML,8.74,6.118,AETNA [1000108],AETNA [100010801],,,76.8,,6.71,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-10,NDC,outpatient,10,ML,4.22,2.954,AETNA [1000108],AETNA [100010801],,,76.8,,3.24,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,AETNA [1000108],AETNA [100010801],,,76.8,,10.66,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,AETNA [1000108],AETNA [100010801],,,76.8,,10.66,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,AETNA [1000108],AETNA [100010801],,,76.8,,2.76,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-50,NDC,outpatient,50,ML,8.74,6.118,AETNA [1000108],AETNA [100010801],,,76.8,,6.71,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-01,NDC,outpatient,10,ML,4.79,3.353,AETNA [1000108],AETNA [100010801],,,76.8,,3.68,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-25,NDC,outpatient,10,ML,4.79,3.353,AETNA [1000108],AETNA [100010801],,,76.8,,3.68,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,AETNA [1000108],AETNA [100010801],,,76.8,,3.13,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0004-04,NDC,outpatient,1000,ML,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0003-47,NDC,outpatient,3000,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,
STOMAHESIVE PASTE PSTE,RX-7493,CDM,S5000,HCPCS,259,RC,68455-0106-90,NDC,outpatient,56.7,GR,38.61,27.027,AETNA [1000108],AETNA [100010801],,,76.8,,29.65,0.222255,85118.57664,percent of total billed charges,
SULFADIAZINE 500 MG ORAL TABS,RX-7554,CDM,S5000,HCPCS,259,RC,42806-0757-60,NDC,outpatient,1,UN,65.91,46.137,AETNA [1000108],AETNA [100010801],,,76.8,,50.62,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-10,NDC,outpatient,10,ML,27.51,19.257,AETNA [1000108],AETNA [100010801],,,76.8,,21.13,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-01,NDC,outpatient,10,ML,27.51,19.257,AETNA [1000108],AETNA [100010801],,,76.8,,21.13,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-01,NDC,outpatient,10,ML,28.26,19.782,AETNA [1000108],AETNA [100010801],,,76.8,,21.7,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-03,NDC,outpatient,10,ML,28.26,19.782,AETNA [1000108],AETNA [100010801],,,76.8,,21.7,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-11,NDC,outpatient,1,UN,1.12,0.784,AETNA [1000108],AETNA [100010801],,,76.8,,0.86,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-65,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-11,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-15,NDC,outpatient,1,UN,1.12,0.784,AETNA [1000108],AETNA [100010801],,,76.8,,0.86,0.222255,85118.57664,percent of total billed charges,
SULFASALAZINE 500 MG ORAL TABS,RX-7562,CDM,S5000,HCPCS,259,RC,59762-5000-05,NDC,outpatient,1,UN,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,00013-0102-50,NDC,outpatient,1,UN,8.65,6.055,AETNA [1000108],AETNA [100010801],,,76.8,,6.64,0.222255,85118.57664,percent of total billed charges,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,59762-0104-05,NDC,outpatient,1,UN,1.47,1.029,AETNA [1000108],AETNA [100010801],,,76.8,,1.13,0.222255,85118.57664,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG ORAL TABS,RX-76444,CDM,S5000,HCPCS,259,RC,49884-0155-76,NDC,outpatient,1,UN,6.79,4.753,AETNA [1000108],AETNA [100010801],,,76.8,,5.21,0.222255,85118.57664,percent of total billed charges,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-11,NDC,outpatient,1,UN,43.68,30.576,AETNA [1000108],AETNA [100010801],,,76.8,,33.55,0.222255,85118.57664,percent of total billed charges,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-21,NDC,outpatient,1,UN,43.68,30.576,AETNA [1000108],AETNA [100010801],,,76.8,,33.55,0.222255,85118.57664,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,S5000,HCPCS,259,RC,24208-0539-20,NDC,outpatient,1,UN,349.11,244.377,AETNA [1000108],AETNA [100010801],,,76.8,,268.12,0.222255,85118.57664,percent of total billed charges,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,39328-0064-12,NDC,outpatient,473,ML,44.21,30.947,AETNA [1000108],AETNA [100010801],,,76.8,,33.95,0.222255,85118.57664,percent of total billed charges,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,00436-0672-16,NDC,outpatient,473,ML,52.63,36.841,AETNA [1000108],AETNA [100010801],,,76.8,,40.42,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-16,NDC,outpatient,7.5,ML,2.05,1.435,AETNA [1000108],AETNA [100010801],,,76.8,,1.57,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-15,NDC,outpatient,15,ML,3.54,2.478,AETNA [1000108],AETNA [100010801],,,76.8,,2.72,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-15,NDC,outpatient,15,ML,19.43,13.601,AETNA [1000108],AETNA [100010801],,,76.8,,14.92,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-40,NDC,outpatient,15,ML,19.43,13.601,AETNA [1000108],AETNA [100010801],,,76.8,,14.92,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-50,NDC,outpatient,15,ML,8.75,6.125,AETNA [1000108],AETNA [100010801],,,76.8,,6.72,0.222255,85118.57664,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-01,NDC,outpatient,15,ML,8.75,6.125,AETNA [1000108],AETNA [100010801],,,76.8,,6.72,0.222255,85118.57664,percent of total billed charges,
VITAMIN D3 25 MCG (1000 UT) ORAL TABS,RX-76997,CDM,S5000,HCPCS,259,RC,20555-0033-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TANNIC ACID POWD,RX-7715,CDM,S5000,HCPCS,259,RC,,,outpatient,20,GR,9.26,6.482,AETNA [1000108],AETNA [100010801],,,76.8,,7.11,0.222255,85118.57664,percent of total billed charges,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-05,NDC,outpatient,10,ML,230.25,161.175,AETNA [1000108],AETNA [100010801],,,76.8,,176.83,0.222255,85118.57664,percent of total billed charges,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-01,NDC,outpatient,10,ML,230.25,161.175,AETNA [1000108],AETNA [100010801],,,76.8,,176.83,0.222255,85118.57664,percent of total billed charges,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-01,NDC,outpatient,1,UN,78.54,54.978,AETNA [1000108],AETNA [100010801],,,76.8,,60.32,0.222255,85118.57664,percent of total billed charges,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-28,NDC,outpatient,1,UN,78.54,54.978,AETNA [1000108],AETNA [100010801],,,76.8,,60.32,0.222255,85118.57664,percent of total billed charges,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-01,NDC,outpatient,1,UN,78.54,54.978,AETNA [1000108],AETNA [100010801],,,76.8,,60.32,0.222255,85118.57664,percent of total billed charges,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-31,NDC,outpatient,1,UN,78.53,54.971,AETNA [1000108],AETNA [100010801],,,76.8,,60.31,0.222255,85118.57664,percent of total billed charges,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-28,NDC,outpatient,1,UN,78.54,54.978,AETNA [1000108],AETNA [100010801],,,76.8,,60.32,0.222255,85118.57664,percent of total billed charges,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,00121-1576-10,NDC,outpatient,10,ML,13.35,9.345,AETNA [1000108],AETNA [100010801],,,76.8,,10.25,0.222255,85118.57664,percent of total billed charges,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,99999-0001-27,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,68682-0920-64,NDC,outpatient,15,ML,325.88,228.116,AETNA [1000108],AETNA [100010801],,,76.8,,250.28,0.222255,85118.57664,percent of total billed charges,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,00065-0741-14,NDC,outpatient,4,ML,54.08,37.856,AETNA [1000108],AETNA [100010801],,,76.8,,41.53,0.222255,85118.57664,percent of total billed charges,
TETRACYCLINE HCL 250 MG ORAL CAPS,RX-7796,CDM,S5000,HCPCS,259,RC,23155-0766-01,NDC,outpatient,1,UN,2.97,2.079,AETNA [1000108],AETNA [100010801],,,76.8,,2.28,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-40,NDC,outpatient,15,ML,35.25,24.675,AETNA [1000108],AETNA [100010801],,,76.8,,27.07,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-71,NDC,outpatient,15,ML,40.12,28.084,AETNA [1000108],AETNA [100010801],,,76.8,,30.81,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-15,NDC,outpatient,15,ML,35.25,24.675,AETNA [1000108],AETNA [100010801],,,76.8,,27.07,0.222255,85118.57664,percent of total billed charges,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-44,NDC,outpatient,15,ML,40.12,28.084,AETNA [1000108],AETNA [100010801],,,76.8,,30.81,0.222255,85118.57664,percent of total billed charges,
THERA ORAL TABS,RX-7825,CDM,S5000,HCPCS,259,RC,00904-0539-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
THERA-DERM EX LOTN,RX-7831,CDM,S5000,HCPCS,259,RC,00904-4299-09,NDC,outpatient,236,ML,8.41,5.887,AETNA [1000108],AETNA [100010801],,,76.8,,6.46,0.222255,85118.57664,percent of total billed charges,
MESALAMINE 1.2 G ORAL TBEC,RX-78310,CDM,S5000,HCPCS,259,RC,00527-3012-48,NDC,outpatient,1,UN,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00395-0413-96,NDC,outpatient,177,ML,11.82,8.274,AETNA [1000108],AETNA [100010801],,,76.8,,9.08,0.222255,85118.57664,percent of total billed charges,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00904-2533-21,NDC,outpatient,177,ML,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.222255,85118.57664,percent of total billed charges,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,49348-0011-34,NDC,outpatient,177,ML,6.31,4.417,AETNA [1000108],AETNA [100010801],,,76.8,,4.85,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-40,NDC,outpatient,5,ML,11.06,7.742,AETNA [1000108],AETNA [100010801],,,76.8,,8.49,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-05,NDC,outpatient,5,ML,11.06,7.742,AETNA [1000108],AETNA [100010801],,,76.8,,8.49,0.222255,85118.57664,percent of total billed charges,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,99999-0002-04,NDC,outpatient,5,ML,1.78,1.246,AETNA [1000108],AETNA [100010801],,,76.8,,1.37,0.222255,85118.57664,percent of total billed charges,
THYROID 30 MG ORAL TABS,RX-7944,CDM,S5000,HCPCS,259,RC,62559-0741-01,NDC,outpatient,1,UN,2.88,2.016,AETNA [1000108],AETNA [100010801],,,76.8,,2.21,0.222255,85118.57664,percent of total billed charges,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,00904-0722-36,NDC,outpatient,14.18,GR,4.36,3.052,AETNA [1000108],AETNA [100010801],,,76.8,,3.35,0.222255,85118.57664,percent of total billed charges,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,49348-0155-29,NDC,outpatient,15,GR,8.88,6.216,AETNA [1000108],AETNA [100010801],,,76.8,,6.82,0.222255,85118.57664,percent of total billed charges,
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,S5000,HCPCS,259,RC,00536-1329-26,NDC,outpatient,45,GR,7.41,5.187,AETNA [1000108],AETNA [100010801],,,76.8,,5.69,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,68382-0807-01,NDC,outpatient,1,UN,1.31,0.917,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-11,NDC,outpatient,1,UN,1.77,1.239,AETNA [1000108],AETNA [100010801],,,76.8,,1.36,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-15,NDC,outpatient,1,UN,1.77,1.239,AETNA [1000108],AETNA [100010801],,,76.8,,1.36,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,60505-2653-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,00904-6868-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,68382-0805-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,50111-0560-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,S5000,HCPCS,259,RC,00168-0003-80,NDC,outpatient,80,GR,21.72,15.204,AETNA [1000108],AETNA [100010801],,,76.8,,16.68,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,67877-0251-80,NDC,outpatient,80,GR,39.16,27.412,AETNA [1000108],AETNA [100010801],,,76.8,,30.07,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,45802-0064-36,NDC,outpatient,80,GR,11.04,7.728,AETNA [1000108],AETNA [100010801],,,76.8,,8.48,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,S5000,HCPCS,259,RC,45802-0065-35,NDC,outpatient,15,GR,20.23,14.161,AETNA [1000108],AETNA [100010801],,,76.8,,15.54,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN,RX-8115,CDM,S5000,HCPCS,259,RC,70752-0129-05,NDC,outpatient,60,ML,126.03,88.221,AETNA [1000108],AETNA [100010801],,,76.8,,96.79,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,00713-0676-53,NDC,outpatient,60,ML,73.43,51.401,AETNA [1000108],AETNA [100010801],,,76.8,,56.39,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,60432-0561-61,NDC,outpatient,60,ML,66.75,46.725,AETNA [1000108],AETNA [100010801],,,76.8,,51.26,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.025 % EX OINT,RX-8117,CDM,S5000,HCPCS,259,RC,00168-0005-80,NDC,outpatient,80,GR,21.01,14.707,AETNA [1000108],AETNA [100010801],,,76.8,,16.14,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,45802-0055-36,NDC,outpatient,80,GR,19.58,13.706,AETNA [1000108],AETNA [100010801],,,76.8,,15.04,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00168-0006-80,NDC,outpatient,80,GR,22.79,15.953,AETNA [1000108],AETNA [100010801],,,76.8,,17.5,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00713-0228-80,NDC,outpatient,80,GR,37.03,25.921,AETNA [1000108],AETNA [100010801],,,76.8,,28.44,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,51672-1284-08,NDC,outpatient,80,GR,43.44,30.408,AETNA [1000108],AETNA [100010801],,,76.8,,33.36,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,S5000,HCPCS,259,RC,33342-0332-15,NDC,outpatient,15,GR,28.77,20.139,AETNA [1000108],AETNA [100010801],,,76.8,,22.1,0.222255,85118.57664,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,S5000,HCPCS,259,RC,64980-0320-05,NDC,outpatient,5,GR,139.78,97.846,AETNA [1000108],AETNA [100010801],,,76.8,,107.35,0.222255,85118.57664,percent of total billed charges,
DIVALPROEX SODIUM ER 500 MG ORAL TB24,RX-81426,CDM,S5000,HCPCS,259,RC,00904-7182-45,NDC,outpatient,1,UN,11.3,7.91,AETNA [1000108],AETNA [100010801],,,76.8,,8.68,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00310-7372-20,NDC,outpatient,10.2,GR,973.53,681.471,AETNA [1000108],AETNA [100010801],,,76.8,,747.67,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00186-0372-28,NDC,outpatient,6.9,GR,250.86,175.602,AETNA [1000108],AETNA [100010801],,,76.8,,192.66,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00310-7370-20,NDC,outpatient,10.2,GR,1011.48,708.036,AETNA [1000108],AETNA [100010801],,,76.8,,776.82,0.222255,85118.57664,percent of total billed charges,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00186-0370-28,NDC,outpatient,6,GR,250.85,175.595,AETNA [1000108],AETNA [100010801],,,76.8,,192.65,0.222255,85118.57664,percent of total billed charges,
TRIFLUOPERAZINE HCL 1 MG ORAL TABS,RX-8161,CDM,S5000,HCPCS,259,RC,00781-8028-01,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,
TRIFLUOPERAZINE HCL 5 MG ORAL TABS,RX-8164,CDM,S5000,HCPCS,259,RC,00781-8034-01,NDC,outpatient,1,UN,4.68,3.276,AETNA [1000108],AETNA [100010801],,,76.8,,3.59,0.222255,85118.57664,percent of total billed charges,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,00591-5335-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,69452-0241-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
TRIHEXYPHENIDYL HCL 5 MG ORAL TABS,RX-8167,CDM,S5000,HCPCS,259,RC,70954-0211-10,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,68180-0407-03,NDC,outpatient,6.25,ML,50.07,35.049,AETNA [1000108],AETNA [100010801],,,76.8,,38.45,0.222255,85118.57664,percent of total billed charges,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,99999-0002-91,NDC,outpatient,6.25,ML,120.07,84.049,AETNA [1000108],AETNA [100010801],,,76.8,,92.21,0.222255,85118.57664,percent of total billed charges,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0070-30,NDC,outpatient,37.5,GR,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0627-63,NDC,outpatient,31,GR,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-15,NDC,outpatient,37.5,GR,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-30,NDC,outpatient,37.5,GR,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0626-53,NDC,outpatient,31,GR,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,50190-0141-23,NDC,outpatient,4,ML,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0207-60,NDC,outpatient,4,ML,3.01,2.107,AETNA [1000108],AETNA [100010801],,,76.8,,2.31,0.222255,85118.57664,percent of total billed charges,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0307-60,NDC,outpatient,4,ML,1.2,0.84,AETNA [1000108],AETNA [100010801],,,76.8,,0.92,0.222255,85118.57664,percent of total billed charges,
THROMBI-GEL 40 EX PADS,RX-82259,CDM,S5000,HCPCS,259,RC,60793-0908-04,NDC,outpatient,1,UN,254.02,177.814,AETNA [1000108],AETNA [100010801],,,76.8,,195.09,0.222255,85118.57664,percent of total billed charges,
TROPICAMIDE 1 % OP SOLN,RX-8250,CDM,S5000,HCPCS,259,RC,70069-0121-01,NDC,outpatient,15,ML,25.3,17.71,AETNA [1000108],AETNA [100010801],,,76.8,,19.43,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-61,NDC,outpatient,1,UN,93.94,65.758,AETNA [1000108],AETNA [100010801],,,76.8,,72.15,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-15,NDC,outpatient,1,UN,93.94,65.758,AETNA [1000108],AETNA [100010801],,,76.8,,72.15,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-03,NDC,outpatient,1,UN,24.46,17.122,AETNA [1000108],AETNA [100010801],,,76.8,,18.79,0.222255,85118.57664,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-11,NDC,outpatient,1,UN,24.46,17.122,AETNA [1000108],AETNA [100010801],,,76.8,,18.79,0.222255,85118.57664,percent of total billed charges,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-78,NDC,outpatient,0.1,ML,35.98,25.186,AETNA [1000108],AETNA [100010801],,,76.8,,27.63,0.222255,85118.57664,percent of total billed charges,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-21,NDC,outpatient,0.1,ML,35.98,25.186,AETNA [1000108],AETNA [100010801],,,76.8,,27.63,0.222255,85118.57664,percent of total billed charges,
UNNA-FLEX ELASTIC UNNA BOOT EX MISC,RX-8371,CDM,S5000,HCPCS,250,RC,68455-0107-63,NDC,outpatient,1,UN,44.16,30.912,AETNA [1000108],AETNA [100010801],,,76.8,,33.91,0.222255,85118.57664,percent of total billed charges,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,69452-0150-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00591-4012-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00832-0310-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT,RX-849,CDM,S5000,HCPCS,259,RC,24208-0785-55,NDC,outpatient,3.5,GR,70.76,49.532,AETNA [1000108],AETNA [100010801],,,76.8,,54.34,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-01,NDC,outpatient,2,ML,15.45,10.815,AETNA [1000108],AETNA [100010801],,,76.8,,11.87,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,70710-1643-07,NDC,outpatient,2,ML,44.5,31.15,AETNA [1000108],AETNA [100010801],,,76.8,,34.18,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-02,NDC,outpatient,2,ML,15.45,10.815,AETNA [1000108],AETNA [100010801],,,76.8,,11.87,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-04,NDC,outpatient,2,ML,15.45,10.815,AETNA [1000108],AETNA [100010801],,,76.8,,11.87,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL 120 MG ORAL TABS,RX-8528,CDM,S5000,HCPCS,259,RC,23155-0486-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL 40 MG ORAL TABS,RX-8529,CDM,S5000,HCPCS,259,RC,23155-0059-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VERAPAMIL HCL 80 MG ORAL TABS,RX-8530,CDM,S5000,HCPCS,259,RC,23155-0026-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,70677-0013-01,NDC,outpatient,28.4,GR,10.49,7.343,AETNA [1000108],AETNA [100010801],,,76.8,,8.06,0.222255,85118.57664,percent of total billed charges,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,49348-0029-72,NDC,outpatient,30,GR,11.49,8.043,AETNA [1000108],AETNA [100010801],,,76.8,,8.82,0.222255,85118.57664,percent of total billed charges,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,S5000,HCPCS,259,RC,00501-3798-05,NDC,outpatient,14.2,GR,20.67,14.469,AETNA [1000108],AETNA [100010801],,,76.8,,15.87,0.222255,85118.57664,percent of total billed charges,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,S5000,HCPCS,259,RC,24208-0555-55,NDC,outpatient,3.5,GR,22.88,16.016,AETNA [1000108],AETNA [100010801],,,76.8,,17.57,0.222255,85118.57664,percent of total billed charges,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,63739-0479-10,NDC,outpatient,1,UN,1.74,1.218,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00904-6475-61,NDC,outpatient,1,UN,1.6,1.12,AETNA [1000108],AETNA [100010801],,,76.8,,1.23,0.222255,85118.57664,percent of total billed charges,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00527-1330-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN E 100 UNITS ORAL CAPS,RX-8698,CDM,S5000,HCPCS,259,RC,80681-0134-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,00536-1352-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-14,NDC,outpatient,5,GR,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-05,NDC,outpatient,5,GR,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-01,NDC,outpatient,1,UN,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-11,NDC,outpatient,1,UN,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-11,NDC,outpatient,1,UN,1.29,0.903,AETNA [1000108],AETNA [100010801],,,76.8,,0.99,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-01,NDC,outpatient,1,UN,1.29,0.903,AETNA [1000108],AETNA [100010801],,,76.8,,0.99,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0205-05,NDC,outpatient,1,UN,228.51,159.957,AETNA [1000108],AETNA [100010801],,,76.8,,175.5,0.222255,85118.57664,percent of total billed charges,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0705-05,NDC,outpatient,1,UN,217.65,152.355,AETNA [1000108],AETNA [100010801],,,76.8,,167.16,0.222255,85118.57664,percent of total billed charges,
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,S5000,HCPCS,259,RC,35181-7303-32,NDC,outpatient,25,GR,146.52,102.564,AETNA [1000108],AETNA [100010801],,,76.8,,112.53,0.222255,85118.57664,percent of total billed charges,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,00023-9211-05,NDC,outpatient,5,ML,838.92,587.244,AETNA [1000108],AETNA [100010801],,,76.8,,644.29,0.222255,85118.57664,percent of total billed charges,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,82182-0455-05,NDC,outpatient,5,ML,356.54,249.578,AETNA [1000108],AETNA [100010801],,,76.8,,273.82,0.222255,85118.57664,percent of total billed charges,
DIAZEPAM 2.5 MG RE GEL,RX-87865,CDM,S5000,HCPCS,259,RC,68682-0650-20,NDC,outpatient,1,UN,430.63,301.441,AETNA [1000108],AETNA [100010801],,,76.8,,330.72,0.222255,85118.57664,percent of total billed charges,
DIAZEPAM 10 MG RE GEL,RX-87867,CDM,S5000,HCPCS,259,RC,68682-0652-20,NDC,outpatient,1,UN,622.96,436.072,AETNA [1000108],AETNA [100010801],,,76.8,,478.43,0.222255,85118.57664,percent of total billed charges,
DIAZEPAM 20 MG RE GEL,RX-87869,CDM,S5000,HCPCS,259,RC,68682-0655-20,NDC,outpatient,1,UN,601.24,420.868,AETNA [1000108],AETNA [100010801],,,76.8,,461.75,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-32,NDC,outpatient,2,ML,38.15,26.705,AETNA [1000108],AETNA [100010801],,,76.8,,29.3,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-01,NDC,outpatient,2,ML,18.21,12.747,AETNA [1000108],AETNA [100010801],,,76.8,,13.99,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-60,NDC,outpatient,2,ML,18.21,12.747,AETNA [1000108],AETNA [100010801],,,76.8,,13.99,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-44,NDC,outpatient,2,ML,11.64,8.148,AETNA [1000108],AETNA [100010801],,,76.8,,8.94,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-60,NDC,outpatient,2,ML,11.64,8.148,AETNA [1000108],AETNA [100010801],,,76.8,,8.94,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-06,NDC,outpatient,2,ML,64.19,44.933,AETNA [1000108],AETNA [100010801],,,76.8,,49.3,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-19,NDC,outpatient,2,ML,64.19,44.933,AETNA [1000108],AETNA [100010801],,,76.8,,49.3,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-93,NDC,outpatient,2,ML,38.15,26.705,AETNA [1000108],AETNA [100010801],,,76.8,,29.3,0.222255,85118.57664,percent of total billed charges,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,49502-0605-61,NDC,outpatient,2,ML,20.29,14.203,AETNA [1000108],AETNA [100010801],,,76.8,,15.58,0.222255,85118.57664,percent of total billed charges,
RALTEGRAVIR POTASSIUM 400 MG ORAL TABS,RX-88608,CDM,S5000,HCPCS,259,RC,00006-0227-61,NDC,outpatient,1,UN,143.66,100.562,AETNA [1000108],AETNA [100010801],,,76.8,,110.33,0.222255,85118.57664,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-11,NDC,outpatient,10,ML,63.68,44.576,AETNA [1000108],AETNA [100010801],,,76.8,,48.91,0.222255,85118.57664,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-01,NDC,outpatient,10,ML,63.68,44.576,AETNA [1000108],AETNA [100010801],,,76.8,,48.91,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,00004-0802-85,NDC,outpatient,1,UN,57.3,40.11,AETNA [1000108],AETNA [100010801],,,76.8,,44.01,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,31722-0630-31,NDC,outpatient,1,UN,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.222255,85118.57664,percent of total billed charges,
OSELTAMIVIR PHOSPHATE 45 MG ORAL CAPS,RX-88705,CDM,S5000,HCPCS,259,RC,00004-0801-85,NDC,outpatient,1,UN,57.3,40.11,AETNA [1000108],AETNA [100010801],,,76.8,,44.01,0.222255,85118.57664,percent of total billed charges,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,00536-1316-98,NDC,outpatient,454,GR,22.23,15.561,AETNA [1000108],AETNA [100010801],,,76.8,,17.07,0.222255,85118.57664,percent of total billed charges,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,75834-0170-01,NDC,outpatient,28.4,GR,13.53,9.471,AETNA [1000108],AETNA [100010801],,,76.8,,10.39,0.222255,85118.57664,percent of total billed charges,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-01,NDC,outpatient,10,ML,75.92,53.144,AETNA [1000108],AETNA [100010801],,,76.8,,58.31,0.222255,85118.57664,percent of total billed charges,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-25,NDC,outpatient,10,ML,75.92,53.144,AETNA [1000108],AETNA [100010801],,,76.8,,58.31,0.222255,85118.57664,percent of total billed charges,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-25,NDC,outpatient,5,ML,189.8,132.86,AETNA [1000108],AETNA [100010801],,,76.8,,145.77,0.222255,85118.57664,percent of total billed charges,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-01,NDC,outpatient,5,ML,189.8,132.86,AETNA [1000108],AETNA [100010801],,,76.8,,145.77,0.222255,85118.57664,percent of total billed charges,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-59,NDC,outpatient,1,UN,6.38,4.466,AETNA [1000108],AETNA [100010801],,,76.8,,4.9,0.222255,85118.57664,percent of total billed charges,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-64,NDC,outpatient,1,UN,6.38,4.466,AETNA [1000108],AETNA [100010801],,,76.8,,4.9,0.222255,85118.57664,percent of total billed charges,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,00904-6707-82,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.222255,85118.57664,percent of total billed charges,
NEBIVOLOL HCL 5 MG ORAL TABS,RX-89284,CDM,S5000,HCPCS,259,RC,00904-7189-04,NDC,outpatient,1,UN,7.99,5.593,AETNA [1000108],AETNA [100010801],,,76.8,,6.14,0.222255,85118.57664,percent of total billed charges,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-10,NDC,outpatient,1,UN,22.14,15.498,AETNA [1000108],AETNA [100010801],,,76.8,,17,0.222255,85118.57664,percent of total billed charges,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-07,NDC,outpatient,1,UN,32.67,22.869,AETNA [1000108],AETNA [100010801],,,76.8,,25.09,0.222255,85118.57664,percent of total billed charges,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-15,NDC,outpatient,1,UN,5.16,3.612,AETNA [1000108],AETNA [100010801],,,76.8,,3.96,0.222255,85118.57664,percent of total billed charges,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-11,NDC,outpatient,1,UN,5.16,3.612,AETNA [1000108],AETNA [100010801],,,76.8,,3.96,0.222255,85118.57664,percent of total billed charges,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,30103-0040-00,NDC,outpatient,60,GR,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,57074-0001-86,NDC,outpatient,60,GR,9.35,6.545,AETNA [1000108],AETNA [100010801],,,76.8,,7.18,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-05,NDC,outpatient,5,ML,4.72,3.304,AETNA [1000108],AETNA [100010801],,,76.8,,3.62,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-59,NDC,outpatient,5,ML,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,99999-0004-23,NDC,outpatient,5,ML,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-00,NDC,outpatient,5,ML,4.72,3.304,AETNA [1000108],AETNA [100010801],,,76.8,,3.62,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-62,NDC,outpatient,5,ML,2.76,1.932,AETNA [1000108],AETNA [100010801],,,76.8,,2.12,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-61,NDC,outpatient,5,ML,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,59676-0570-01,NDC,outpatient,1,UN,53.89,37.723,AETNA [1000108],AETNA [100010801],,,76.8,,41.39,0.222255,85118.57664,percent of total billed charges,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,60219-1721-07,NDC,outpatient,1,UN,36.43,25.501,AETNA [1000108],AETNA [100010801],,,76.8,,27.98,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-23,NDC,outpatient,1,UN,1.51,1.057,AETNA [1000108],AETNA [100010801],,,76.8,,1.16,0.222255,85118.57664,percent of total billed charges,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-62,NDC,outpatient,1,UN,1.51,1.057,AETNA [1000108],AETNA [100010801],,,76.8,,1.16,0.222255,85118.57664,percent of total billed charges,
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,S5000,HCPCS,250,RC,00338-0322-01,NDC,outpatient,1,UN,281.38,196.966,AETNA [1000108],AETNA [100010801],,,76.8,,216.1,0.222255,85118.57664,percent of total billed charges,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-11,NDC,outpatient,1,UN,4.66,3.262,AETNA [1000108],AETNA [100010801],,,76.8,,3.58,0.222255,85118.57664,percent of total billed charges,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,10702-0253-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00904-6938-06,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.222255,85118.57664,percent of total billed charges,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-65,NDC,outpatient,1,UN,4.66,3.262,AETNA [1000108],AETNA [100010801],,,76.8,,3.58,0.222255,85118.57664,percent of total billed charges,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00527-1695-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ACETIC ACID 0.25 % IR SOLN,RX-8963,CDM,S5000,HCPCS,250,RC,00338-0656-04,NDC,outpatient,1000,ML,13.35,9.345,AETNA [1000108],AETNA [100010801],,,76.8,,10.25,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,00187-0994-45,NDC,outpatient,5,GR,822.36,575.652,AETNA [1000108],AETNA [100010801],,,76.8,,631.57,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,45802-0044-75,NDC,outpatient,5,GR,210.13,147.091,AETNA [1000108],AETNA [100010801],,,76.8,,161.38,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,00904-5789-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,60505-0042-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,31722-0681-47,NDC,outpatient,473,ML,244.17,170.919,AETNA [1000108],AETNA [100010801],,,76.8,,187.52,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,00472-0082-16,NDC,outpatient,473,ML,1582.85,1107.995,AETNA [1000108],AETNA [100010801],,,76.8,,1215.63,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,99999-0004-02,NDC,outpatient,5,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-01,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-11,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-73,NDC,outpatient,30,ML,11.09,7.763,AETNA [1000108],AETNA [100010801],,,76.8,,8.52,0.222255,85118.57664,percent of total billed charges,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,57896-0629-12,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-01,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-30,NDC,outpatient,30,ML,1.7,1.19,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-62,NDC,outpatient,30,ML,11.09,7.763,AETNA [1000108],AETNA [100010801],,,76.8,,8.52,0.222255,85118.57664,percent of total billed charges,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00121-1761-30,NDC,outpatient,30,ML,7.21,5.047,AETNA [1000108],AETNA [100010801],,,76.8,,5.54,0.222255,85118.57664,percent of total billed charges,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,99999-0002-58,NDC,outpatient,30,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMINOCAPROIC ACID 500 MG ORAL TABS,RX-9063,CDM,S5000,HCPCS,259,RC,69680-0115-30,NDC,outpatient,1,UN,26.56,18.592,AETNA [1000108],AETNA [100010801],,,76.8,,20.4,0.222255,85118.57664,percent of total billed charges,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00904-6993-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,63739-0051-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMLODIPINE BESYLATE 2.5 MG ORAL TABS,RX-9070,CDM,S5000,HCPCS,259,RC,00904-6369-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,68382-0122-16,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,00904-6370-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,64850-0502-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,42806-0341-01,NDC,outpatient,1,UN,1.52,1.064,AETNA [1000108],AETNA [100010801],,,76.8,,1.17,0.222255,85118.57664,percent of total billed charges,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00591-3659-30,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,51991-0311-90,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00008-1211-14,NDC,outpatient,1,UN,5.76,4.032,AETNA [1000108],AETNA [100010801],,,76.8,,4.42,0.222255,85118.57664,percent of total billed charges,
ROPINIROLE HCL ER 2 MG ORAL TB24,RX-92015,CDM,S5000,HCPCS,259,RC,55111-0659-30,NDC,outpatient,1,UN,2.69,1.883,AETNA [1000108],AETNA [100010801],,,76.8,,2.07,0.222255,85118.57664,percent of total billed charges,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-11,NDC,outpatient,1,UN,2.09,1.463,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-15,NDC,outpatient,1,UN,2.09,1.463,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,S5000,HCPCS,259,RC,61314-0245-01,NDC,outpatient,5,ML,147.74,103.418,AETNA [1000108],AETNA [100010801],,,76.8,,113.46,0.222255,85118.57664,percent of total billed charges,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10702-0013-01,NDC,outpatient,1,UN,1.58,1.106,AETNA [1000108],AETNA [100010801],,,76.8,,1.21,0.222255,85118.57664,percent of total billed charges,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10135-0623-01,NDC,outpatient,1,UN,2.28,1.596,AETNA [1000108],AETNA [100010801],,,76.8,,1.75,0.222255,85118.57664,percent of total billed charges,
MOUTH KOTE MT SOLN,RX-92764,CDM,S5000,HCPCS,259,RC,50930-0098-02,NDC,outpatient,59,ML,21.53,15.071,AETNA [1000108],AETNA [100010801],,,76.8,,16.54,0.222255,85118.57664,percent of total billed charges,
BROMOCRIPTINE MESYLATE 2.5 MG ORAL TABS,RX-9297,CDM,S5000,HCPCS,259,RC,00574-0106-03,NDC,outpatient,1,UN,3.28,2.296,AETNA [1000108],AETNA [100010801],,,76.8,,2.52,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,42799-0119-01,NDC,outpatient,1,UN,1.43,1.001,AETNA [1000108],AETNA [100010801],,,76.8,,1.1,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-15,NDC,outpatient,1,UN,5.55,3.885,AETNA [1000108],AETNA [100010801],,,76.8,,4.26,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-11,NDC,outpatient,1,UN,5.55,3.885,AETNA [1000108],AETNA [100010801],,,76.8,,4.26,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-05,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-15,NDC,outpatient,1,UN,3.09,2.163,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-11,NDC,outpatient,1,UN,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-11,NDC,outpatient,1,UN,3.09,2.163,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-01,NDC,outpatient,1,UN,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,69238-1490-01,NDC,outpatient,1,UN,1.61,1.127,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-57,NDC,outpatient,50,ML,49.4,34.58,AETNA [1000108],AETNA [100010801],,,76.8,,37.94,0.222255,85118.57664,percent of total billed charges,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-01,NDC,outpatient,50,ML,49.4,34.58,AETNA [1000108],AETNA [100010801],,,76.8,,37.94,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL 100 MG ORAL TABS,RX-9321,CDM,S5000,HCPCS,259,RC,00904-6636-61,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-11,NDC,outpatient,1,UN,2.99,2.093,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-15,NDC,outpatient,1,UN,2.99,2.093,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-01,NDC,outpatient,1,UN,3.85,2.695,AETNA [1000108],AETNA [100010801],,,76.8,,2.96,0.222255,85118.57664,percent of total billed charges,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-11,NDC,outpatient,1,UN,3.85,2.695,AETNA [1000108],AETNA [100010801],,,76.8,,2.96,0.222255,85118.57664,percent of total billed charges,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00093-0053-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00904-7122-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,23155-0662-01,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,69452-0207-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-33,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.222255,85118.57664,percent of total billed charges,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,66553-0004-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,00904-6412-92,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-32,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.222255,85118.57664,percent of total billed charges,
SORBITOL 70 % SOLN,RX-93927,CDM,S5000,HCPCS,259,RC,46287-0500-30,NDC,outpatient,30,ML,9.48,6.636,AETNA [1000108],AETNA [100010801],,,76.8,,7.28,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-31,NDC,outpatient,3,ML,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-01,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-03,NDC,outpatient,3,ML,1.13,0.791,AETNA [1000108],AETNA [100010801],,,76.8,,0.87,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,76204-0600-01,NDC,outpatient,3,ML,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-30,NDC,outpatient,3,ML,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-60,NDC,outpatient,3,ML,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-93,NDC,outpatient,3,ML,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-49,NDC,outpatient,3,ML,1.42,0.994,AETNA [1000108],AETNA [100010801],,,76.8,,1.09,0.222255,85118.57664,percent of total billed charges,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-48,NDC,outpatient,3,ML,1.42,0.994,AETNA [1000108],AETNA [100010801],,,76.8,,1.09,0.222255,85118.57664,percent of total billed charges,
CAPTOPRIL 12.5 MG ORAL TABS,RX-9401,CDM,S5000,HCPCS,259,RC,00904-7105-61,NDC,outpatient,1,UN,6.29,4.403,AETNA [1000108],AETNA [100010801],,,76.8,,4.83,0.222255,85118.57664,percent of total billed charges,
CAPTOPRIL 25 MG ORAL TABS,RX-9402,CDM,S5000,HCPCS,259,RC,00904-7106-61,NDC,outpatient,1,UN,5.2,3.64,AETNA [1000108],AETNA [100010801],,,76.8,,3.99,0.222255,85118.57664,percent of total billed charges,
CARBIDOPA-LEVODOPA 10-100 MG ORAL TABS,RX-9406,CDM,S5000,HCPCS,259,RC,00093-9701-01,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,00093-9702-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-05,NDC,outpatient,1,ML,319.49,223.643,AETNA [1000108],AETNA [100010801],,,76.8,,245.37,0.222255,85118.57664,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-08,NDC,outpatient,1,ML,319.49,223.643,AETNA [1000108],AETNA [100010801],,,76.8,,245.37,0.222255,85118.57664,percent of total billed charges,
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,S5000,HCPCS,259,RC,00904-6255-49,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,60258-0162-01,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,63044-0622-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CEFACLOR 250 MG ORAL CAPS,RX-9430,CDM,S5000,HCPCS,259,RC,61442-0171-30,NDC,outpatient,1,UN,8.1,5.67,AETNA [1000108],AETNA [100010801],,,76.8,,6.22,0.222255,85118.57664,percent of total billed charges,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,16714-0388-01,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,65862-0085-50,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-01,NDC,outpatient,1,UN,2.36,1.652,AETNA [1000108],AETNA [100010801],,,76.8,,1.81,0.222255,85118.57664,percent of total billed charges,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-08,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,65862-0096-20,NDC,outpatient,1,UN,14.53,10.171,AETNA [1000108],AETNA [100010801],,,76.8,,11.16,0.222255,85118.57664,percent of total billed charges,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,00781-5439-20,NDC,outpatient,1,UN,12.33,8.631,AETNA [1000108],AETNA [100010801],,,76.8,,9.47,0.222255,85118.57664,percent of total billed charges,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,16714-0400-02,NDC,outpatient,1,UN,3.64,2.548,AETNA [1000108],AETNA [100010801],,,76.8,,2.8,0.222255,85118.57664,percent of total billed charges,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,67877-0215-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,65862-0699-60,NDC,outpatient,1,UN,2.34,1.638,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-01,NDC,outpatient,1,UN,1.3,0.91,AETNA [1000108],AETNA [100010801],,,76.8,,1,0.222255,85118.57664,percent of total billed charges,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,67877-0220-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-11,NDC,outpatient,1,UN,1.49,1.043,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-15,NDC,outpatient,1,UN,1.49,1.043,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-11,NDC,outpatient,1,UN,1.3,0.91,AETNA [1000108],AETNA [100010801],,,76.8,,1,0.222255,85118.57664,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-19,NDC,outpatient,15,ML,6.15,4.305,AETNA [1000108],AETNA [100010801],,,76.8,,4.72,0.222255,85118.57664,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-15,NDC,outpatient,15,ML,6.55,4.585,AETNA [1000108],AETNA [100010801],,,76.8,,5.03,0.222255,85118.57664,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,5.99,4.193,AETNA [1000108],AETNA [100010801],,,76.8,,4.6,0.222255,85118.57664,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,1,ML,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,54838-0011-50,NDC,outpatient,50,ML,14.02,9.814,AETNA [1000108],AETNA [100010801],,,76.8,,10.77,0.222255,85118.57664,percent of total billed charges,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,99999-0003-94,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,61314-0656-05,NDC,outpatient,5,ML,15.4,10.78,AETNA [1000108],AETNA [100010801],,,76.8,,11.83,0.222255,85118.57664,percent of total billed charges,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,69315-0308-05,NDC,outpatient,5,ML,62.3,43.61,AETNA [1000108],AETNA [100010801],,,76.8,,47.85,0.222255,85118.57664,percent of total billed charges,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,00527-1931-06,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,65862-0225-60,NDC,outpatient,1,UN,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,59762-3743-01,NDC,outpatient,30,GR,208.26,145.782,AETNA [1000108],AETNA [100010801],,,76.8,,159.94,0.222255,85118.57664,percent of total billed charges,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,00168-0202-30,NDC,outpatient,30,GR,207.33,145.131,AETNA [1000108],AETNA [100010801],,,76.8,,159.23,0.222255,85118.57664,percent of total billed charges,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,51672-1258-02,NDC,outpatient,30,GR,31.11,21.777,AETNA [1000108],AETNA [100010801],,,76.8,,23.89,0.222255,85118.57664,percent of total billed charges,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,69238-1532-05,NDC,outpatient,15,GR,19.83,13.881,AETNA [1000108],AETNA [100010801],,,76.8,,15.23,0.222255,85118.57664,percent of total billed charges,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,51672-1259-02,NDC,outpatient,30,GR,43.53,30.471,AETNA [1000108],AETNA [100010801],,,76.8,,33.43,0.222255,85118.57664,percent of total billed charges,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,21922-0017-05,NDC,outpatient,30,GR,42.19,29.533,AETNA [1000108],AETNA [100010801],,,76.8,,32.4,0.222255,85118.57664,percent of total billed charges,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-25,NDC,outpatient,1,UN,36.81,25.767,AETNA [1000108],AETNA [100010801],,,76.8,,28.27,0.222255,85118.57664,percent of total billed charges,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-95,NDC,outpatient,1,UN,36.81,25.767,AETNA [1000108],AETNA [100010801],,,76.8,,28.27,0.222255,85118.57664,percent of total billed charges,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-11,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,43547-0407-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,16729-0137-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-11,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00054-4146-22,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00574-0107-70,NDC,outpatient,1,UN,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-20,NDC,outpatient,1,UN,4.21,2.947,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-01,NDC,outpatient,1,UN,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-11,NDC,outpatient,1,UN,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-01,NDC,outpatient,1,UN,4.21,2.947,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-20,NDC,outpatient,1,UN,2.14,1.498,AETNA [1000108],AETNA [100010801],,,76.8,,1.64,0.222255,85118.57664,percent of total billed charges,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-01,NDC,outpatient,1,UN,2.14,1.498,AETNA [1000108],AETNA [100010801],,,76.8,,1.64,0.222255,85118.57664,percent of total billed charges,
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,S5000,HCPCS,259,RC,50484-0010-30,NDC,outpatient,30,GR,1218.46,852.922,AETNA [1000108],AETNA [100010801],,,76.8,,935.78,0.222255,85118.57664,percent of total billed charges,
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,S5000,HCPCS,259,RC,61314-0237-10,NDC,outpatient,10,ML,27.77,19.439,AETNA [1000108],AETNA [100010801],,,76.8,,21.33,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,68462-0678-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-35,NDC,outpatient,1,UN,48.43,33.901,AETNA [1000108],AETNA [100010801],,,76.8,,37.19,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-60,NDC,outpatient,1,UN,53.28,37.296,AETNA [1000108],AETNA [100010801],,,76.8,,40.92,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,00131-2478-60,NDC,outpatient,1,UN,83.29,58.303,AETNA [1000108],AETNA [100010801],,,76.8,,63.97,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,31722-0813-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,51991-0349-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-11,NDC,outpatient,1,UN,5.37,3.759,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-57,NDC,outpatient,1,UN,5.37,3.759,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,S5000,HCPCS,259,RC,00065-0397-02,NDC,outpatient,2,ML,180.67,126.469,AETNA [1000108],AETNA [100010801],,,76.8,,138.75,0.222255,85118.57664,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,S5000,HCPCS,259,RC,00065-0359-02,NDC,outpatient,2,ML,144.23,100.961,AETNA [1000108],AETNA [100010801],,,76.8,,110.77,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-61,NDC,outpatient,1,UN,74.28,51.996,AETNA [1000108],AETNA [100010801],,,76.8,,57.05,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,60505-0134-00,NDC,outpatient,1,UN,46.97,32.879,AETNA [1000108],AETNA [100010801],,,76.8,,36.07,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-15,NDC,outpatient,1,UN,74.28,51.996,AETNA [1000108],AETNA [100010801],,,76.8,,57.05,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-15,NDC,outpatient,1,UN,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-61,NDC,outpatient,1,UN,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-25,NDC,outpatient,1,UN,18.44,12.908,AETNA [1000108],AETNA [100010801],,,76.8,,14.16,0.222255,85118.57664,percent of total billed charges,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-95,NDC,outpatient,1,UN,18.44,12.908,AETNA [1000108],AETNA [100010801],,,76.8,,14.16,0.222255,85118.57664,percent of total billed charges,
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,S5000,HCPCS,250,RC,42023-0123-06,NDC,outpatient,1,UN,288.51,201.957,AETNA [1000108],AETNA [100010801],,,76.8,,221.58,0.222255,85118.57664,percent of total billed charges,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00115-4411-01,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00904-7211-04,NDC,outpatient,1,UN,4.53,3.171,AETNA [1000108],AETNA [100010801],,,76.8,,3.48,0.222255,85118.57664,percent of total billed charges,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,55150-0173-01,NDC,outpatient,0.5,ML,17.69,12.383,AETNA [1000108],AETNA [100010801],,,76.8,,13.59,0.222255,85118.57664,percent of total billed charges,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,63323-0273-01,NDC,outpatient,0.5,ML,24.66,17.262,AETNA [1000108],AETNA [100010801],,,76.8,,18.94,0.222255,85118.57664,percent of total billed charges,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,99999-0002-38,NDC,outpatient,10,ML,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,60432-0608-16,NDC,outpatient,10,ML,3.48,2.436,AETNA [1000108],AETNA [100010801],,,76.8,,2.67,0.222255,85118.57664,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-00,NDC,outpatient,10,ML,7.53,5.271,AETNA [1000108],AETNA [100010801],,,76.8,,5.78,0.222255,85118.57664,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,99999-0001-87,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00904-7135-72,NDC,outpatient,10,ML,6.5,4.55,AETNA [1000108],AETNA [100010801],,,76.8,,4.99,0.222255,85118.57664,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-10,NDC,outpatient,10,ML,1.7,1.19,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-10,NDC,outpatient,10,ML,7.53,5.271,AETNA [1000108],AETNA [100010801],,,76.8,,5.78,0.222255,85118.57664,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-10,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-34,NDC,outpatient,118,ML,8.93,6.251,AETNA [1000108],AETNA [100010801],,,76.8,,6.86,0.222255,85118.57664,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-04,NDC,outpatient,118,ML,17.33,12.131,AETNA [1000108],AETNA [100010801],,,76.8,,13.31,0.222255,85118.57664,percent of total billed charges,
TOLVAPTAN 15 MG ORAL TABS,RX-97893,CDM,S5000,HCPCS,259,RC,59148-0020-50,NDC,outpatient,1,UN,1428.57,999.999,AETNA [1000108],AETNA [100010801],,,76.8,,1097.14,0.222255,85118.57664,percent of total billed charges,
PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS ORAL CPEP,RX-98034,CDM,S5000,HCPCS,259,RC,00032-0046-70,NDC,outpatient,1,UN,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,0.222255,85118.57664,percent of total billed charges,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-1224-01,NDC,outpatient,1,UN,33.86,23.702,AETNA [1000108],AETNA [100010801],,,76.8,,26,0.222255,85118.57664,percent of total billed charges,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-2636-01,NDC,outpatient,1,UN,33.86,23.702,AETNA [1000108],AETNA [100010801],,,76.8,,26,0.222255,85118.57664,percent of total billed charges,
DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN,RX-9809,CDM,S5000,HCPCS,250,RC,00264-7622-00,NDC,outpatient,1000,ML,51.6,36.12,AETNA [1000108],AETNA [100010801],,,76.8,,39.63,0.222255,85118.57664,percent of total billed charges,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-9812,CDM,S5000,HCPCS,250,RC,00338-0077-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.222255,85118.57664,percent of total billed charges,
DEXTROSE-SODIUM CHLORIDE 5-0.33 % IV SOLN,RX-9813,CDM,S5000,HCPCS,250,RC,00264-7614-10,NDC,outpatient,500,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.222255,85118.57664,percent of total billed charges,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,0.222255,85118.57664,percent of total billed charges,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.222255,85118.57664,percent of total billed charges,
DRONEDARONE HCL 400 MG ORAL TABS,RX-98329,CDM,S5000,HCPCS,259,RC,00024-4142-60,NDC,outpatient,1,UN,53.6,37.52,AETNA [1000108],AETNA [100010801],,,76.8,,41.16,0.222255,85118.57664,percent of total billed charges,
PRASUGREL HCL 5 MG ORAL TABS,RX-98372,CDM,S5000,HCPCS,259,RC,60505-4642-03,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,1,UN,2.9,2.03,AETNA [1000108],AETNA [100010801],,,76.8,,2.23,0.222255,85118.57664,percent of total billed charges,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,1,UN,4.12,2.884,AETNA [1000108],AETNA [100010801],,,76.8,,3.16,0.222255,85118.57664,percent of total billed charges,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,1,UN,1,0.7,AETNA [1000108],AETNA [100010801],,,76.8,,0.77,0.222255,85118.57664,percent of total billed charges,
BENZOIN COMPOUND EX TINC,RX-987,CDM,S5000,HCPCS,259,RC,00395-0243-92,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DINOPROSTONE 0.5 MG/3GM VA GEL,RX-9874,CDM,S5000,HCPCS,259,RC,00009-3359-01,NDC,outpatient,3,GR,1932.45,1352.715,AETNA [1000108],AETNA [100010801],,,76.8,,1484.12,0.222255,85118.57664,percent of total billed charges,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,00904-7153-61,NDC,outpatient,1,UN,1.32,0.924,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,42806-0714-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,64380-0712-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,69452-0143-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-25,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,00904-5522-61,NDC,outpatient,1,UN,2.36,1.652,AETNA [1000108],AETNA [100010801],,,76.8,,1.81,0.222255,85118.57664,percent of total billed charges,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-95,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,16729-0213-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,60505-0095-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,00904-5524-61,NDC,outpatient,1,UN,2.28,1.596,AETNA [1000108],AETNA [100010801],,,76.8,,1.75,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,68180-0657-01,NDC,outpatient,20,ML,27.06,18.942,AETNA [1000108],AETNA [100010801],,,76.8,,20.78,0.222255,85118.57664,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,99999-0002-89,NDC,outpatient,20,ML,27.06,18.942,AETNA [1000108],AETNA [100010801],,,76.8,,20.78,0.222255,85118.57664,percent of total billed charges,
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,S5000,HCPCS,259,RC,51672-1303-01,NDC,outpatient,15,GR,32.65,22.855,AETNA [1000108],AETNA [100010801],,,76.8,,25.08,0.222255,85118.57664,percent of total billed charges,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,23155-0772-01,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,43547-0547-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ENALAPRIL MALEATE 2.5 MG ORAL TABS,RX-9925,CDM,S5000,HCPCS,259,RC,16714-0442-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-01,NDC,outpatient,2,ML,34.39,24.073,AETNA [1000108],AETNA [100010801],,,76.8,,26.41,0.222255,85118.57664,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-10,NDC,outpatient,2,ML,34.39,24.073,AETNA [1000108],AETNA [100010801],,,76.8,,26.41,0.222255,85118.57664,percent of total billed charges,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,99999-0002-24,NDC,outpatient,0.6,ML,13.98,9.786,AETNA [1000108],AETNA [100010801],,,76.8,,10.74,0.222255,85118.57664,percent of total billed charges,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,42799-0217-01,NDC,outpatient,0.6,ML,13.98,9.786,AETNA [1000108],AETNA [100010801],,,76.8,,10.74,0.222255,85118.57664,percent of total billed charges,
GLYCERIN (LAXATIVE) 1 G RE SUPP,RX-99417,CDM,S5000,HCPCS,259,RC,58980-0409-12,NDC,outpatient,1,UN,2.17,1.519,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0162-88,NDC,outpatient,1,UN,133.64,93.548,AETNA [1000108],AETNA [100010801],,,76.8,,102.64,0.222255,85118.57664,percent of total billed charges,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0146-19,NDC,outpatient,1,UN,133.73,93.611,AETNA [1000108],AETNA [100010801],,,76.8,,102.7,0.222255,85118.57664,percent of total billed charges,
ESTROGENS CONJUGATED 0.3 MG ORAL TABS,RX-9973,CDM,S5000,HCPCS,259,RC,00046-1100-81,NDC,outpatient,1,UN,28.4,19.88,AETNA [1000108],AETNA [100010801],,,76.8,,21.81,0.222255,85118.57664,percent of total billed charges,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,42023-0157-01,NDC,outpatient,1,UN,1563.3,1094.31,AETNA [1000108],AETNA [100010801],,,76.8,,1200.61,0.222255,85118.57664,percent of total billed charges,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,67457-0297-50,NDC,outpatient,1,UN,2098.98,1469.286,AETNA [1000108],AETNA [100010801],,,76.8,,1612.02,0.222255,85118.57664,percent of total billed charges,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-01,NDC,outpatient,1,UN,1.82,1.274,AETNA [1000108],AETNA [100010801],,,76.8,,1.4,0.222255,85118.57664,percent of total billed charges,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-11,NDC,outpatient,1,UN,1.82,1.274,AETNA [1000108],AETNA [100010801],,,76.8,,1.4,0.222255,85118.57664,percent of total billed charges,
ETHACRYNIC ACID 25 MG ORAL TABS,RX-9980,CDM,S5000,HCPCS,259,RC,69238-1126-01,NDC,outpatient,1,UN,8.7,6.09,AETNA [1000108],AETNA [100010801],,,76.8,,6.68,0.222255,85118.57664,percent of total billed charges,
ETHAMBUTOL HCL 400 MG ORAL TABS,RX-9983,CDM,S5000,HCPCS,259,RC,68850-0012-02,NDC,outpatient,1,UN,3.21,2.247,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.222255,85118.57664,percent of total billed charges,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,60505-3927-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,24979-0533-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
GUANFACINE HCL ER 2 MG ORAL TB24,RX-99836,CDM,S5000,HCPCS,259,RC,62332-0746-31,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,23155-0532-01,NDC,outpatient,1,UN,5.34,3.738,AETNA [1000108],AETNA [100010801],,,76.8,,4.1,0.222255,85118.57664,percent of total billed charges,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,64380-0878-06,NDC,outpatient,1,UN,1.63,1.141,AETNA [1000108],AETNA [100010801],,,76.8,,1.25,0.222255,85118.57664,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-01,NDC,outpatient,1,UN,1.62,1.134,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-11,NDC,outpatient,1,UN,1.62,1.134,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,62559-0250-01,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,60505-0039-01,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,
ETODOLAC 300 MG ORAL CAPS,RX-9998,CDM,S5000,HCPCS,259,RC,62559-0251-01,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,
HC Crisis Intervention Mental Health Services- per Diem,PX-90000001,CDM,S9485,HCPCS,900,RC,,,outpatient,,,1627,1138.9,AETNA [1000108],AETNA [100010801],,,76.8,,1249.54,365.2615,1249.536,percent of total billed charges,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,outpatient,,,10370,7259,AETNA [1000108],AETNA [100010801],,,76.8,,7964.16,399.86,9291.52,percent of total billed charges,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,outpatient,,,7029,4920.3,AETNA [1000108],AETNA [100010801],,,76.8,,5398.27,399.86,9291.52,percent of total billed charges,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,129.686915,921.62304,percent of total billed charges,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,129.686915,921.62304,percent of total billed charges,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,129.686915,921.62304,percent of total billed charges,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,AETNA [1000108],AETNA [100010801],,,76.8,,921.62,129.686915,921.62304,percent of total billed charges,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,AETNA [1000108],AETNA [100010801],,,76.8,,921.62,129.686915,921.62304,percent of total billed charges,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,129.686915,921.62304,percent of total billed charges,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,129.686915,921.62304,percent of total billed charges,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,137.54666,3281.45664,percent of total billed charges,
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,76.8,,470.54,137.54666,3281.45664,percent of total billed charges,
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,76.8,,470.54,137.54666,3281.45664,percent of total billed charges,
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,137.54666,3281.45664,percent of total billed charges,
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,137.54666,3281.45664,percent of total billed charges,
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,137.54666,3281.45664,percent of total billed charges,
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,137.54666,3281.45664,percent of total billed charges,
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,137.54666,3281.45664,percent of total billed charges,
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,76.8,,600.49,137.54666,3281.45664,percent of total billed charges,
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,76.8,,600.49,137.54666,3281.45664,percent of total billed charges,
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,137.54666,3281.45664,percent of total billed charges,
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,399.86,2223.8905,percent of total billed charges,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,399.86,3992.7552,percent of total billed charges,
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,399.86,3992.7552,percent of total billed charges,
Bilateral procedure,,,,,,,,,,,,,,AETNA [1000108],AETNA [100010801],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,525.9295,1261.6,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,808.0705,1938.4,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,731.3655,1754.4,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1108.2205,2658.4,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,594.6305,2483,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,444.5555,1066.4,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,398.5325,956,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1337.0015,3207.2,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1215.941,2916.8,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,672.0025,1612,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1604.135,3848,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.205,72,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.491,94.4,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.3685,90.4,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,17.96,64,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,17.7355,63.2,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,59.9415,213.6,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.205,72,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.309,225.6,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.166,214.4,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.5335,226.4,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.9825,228,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,64.4315,229.6,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,68.9215,245.6,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,94.9635,338.4,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,98.331,350.4,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,118.7605,423.2,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,118.7605,423.2,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,183.192,652.8,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,871.958,3107.2,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1098.0295,3912.8,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1176.829,4193.6,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1227.117,4372.8,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,149.7415,533.6,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.2485,282.4,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,73.4115,261.6,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,87.555,312,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,158.7215,565.6,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,32.328,122.0544,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,58.819,222.0712,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,61.064,230.5472,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,68.697,259.3656,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,84.6365,319.5452,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,105.7395,399.2196,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,110.005,415.324,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,210.8055,795.8964,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.756,74.5888,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.3275,80.522,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.246,91.5408,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,28.736,108.4928,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,43.3285,163.5868,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,43.7775,165.282,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.5125,190.71,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.1465,302.5932,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.1465,302.5932,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.1465,302.5932,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,83.963,317.0024,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,88.902,335.6496,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,90.249,340.7352,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,91.8205,346.6684,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,93.841,354.2968,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,93.6165,353.4492,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.127,378.0296,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,101.2495,382.2676,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.617,394.9816,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.617,394.9816,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,105.515,398.372,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.556,413.6288,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,115.842,437.3616,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,116.5155,439.9044,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,117.4135,443.2948,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,121.4545,458.5516,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,121.4545,458.5516,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,124.822,471.2656,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,151.313,571.2824,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.803,588.2344,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.803,588.2344,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.803,588.2344,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.8235,595.8628,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,161.4155,609.4244,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,162.089,611.9672,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,164.1095,619.5956,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,171.7425,648.414,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.212,657.7376,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.212,657.7376,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,189.7025,716.222,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,189.7025,716.222,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,189.7025,716.222,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.9275,758.602,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.9275,758.602,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,185.6615,700.9652,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,210.8055,795.8964,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,219.7855,829.8004,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,354.9345,1340.0556,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,354.9345,1340.0556,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,255.032,962.8736,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,284.8905,1075.6044,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,296.1155,1117.9844,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,314.0755,1185.7924,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,316.096,1193.4208,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,455.0615,1718.0852,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,498.1655,1880.8244,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,584.149,2205.4552,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,660.7035,2494.4868,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1249.3425,4716.894,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1237.444,4671.9712,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,924.94,3492.112,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1237.444,4671.9712,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,302.8505,1143.4124,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.7555,33.0564,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,277.931,1049.3288,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,249.8685,943.3788,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,423.6315,1599.4212,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,246.2765,929.8172,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,337.648,1274.7904,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,71.6155,270.3844,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,103.719,391.5912,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,241.7865,912.8652,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.107,411.9336,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.3515,378.8772,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,299.034,1129.0032,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,66.6765,251.7372,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,120.5565,455.1612,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,126.8425,478.894,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,93.6165,353.4492,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,92.494,349.2112,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.1295,585.6916,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,113.597,428.8856,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,95.188,359.3824,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,133.353,503.4744,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,118.7605,448.3804,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,203.397,767.9256,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.476,549.2448,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,222.255,839.124,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,194.1925,733.174,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,97.2085,367.0108,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,88.453,333.9544,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,136.047,513.6456,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.15,593.32,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,495.0225,1868.958,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,299.932,1132.3936,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,245.603,927.2744,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,266.706,1006.9488,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,259.073,978.1304,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,259.073,978.1304,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,176.2325,665.366,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.8855,660.2804,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,267.3795,1009.4916,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,220.6835,833.1908,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,102.5965,387.3532,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,105.7395,399.2196,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.3925,394.134,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,184.7635,697.5748,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,138.9655,524.6644,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,178.4775,673.842,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,162.089,611.9672,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,55.0025,207.662,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,214.173,808.6104,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,259.073,978.1304,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,111.5765,421.2572,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,56.3495,212.7476,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,91.596,345.8208,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.3515,378.8772,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.5955,304.2884,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.044,264.4512,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.044,264.4512,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,139.639,527.2072,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,123.924,467.8752,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,274.1145,1034.9196,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,846.814,3197.1472,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,438.673,1656.2104,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,854.447,3225.9656,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,148.3945,560.2636,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.965,483.132,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.965,483.132,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,759.9325,2869.126,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,715.0325,2699.606,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,85.31,322.088,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.8855,660.2804,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,74.085,279.708,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,85.759,323.7832,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.576,379.7248,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.1885,400.9148,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.699,425.4952,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,147.721,557.7208,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,148.3945,560.2636,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.8235,595.8628,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,167.2525,631.462,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,176.2325,665.366,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,202.2745,763.6876,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,205.4175,775.554,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,250.7665,946.7692,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,574.72,2169.856,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,574.72,2169.856,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,667.663,2520.7624,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,675.9695,2552.1236,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,675.9695,2552.1236,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,710.5425,2682.654,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,767.341,2897.0968,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,777.219,2934.3912,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1481.0265,5591.6172,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,147.721,557.7208,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,147.721,557.7208,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,276.584,1044.2432,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,392.875,1483.3,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,882.9585,3333.6108,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,923.593,3487.0264,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1001.4945,3781.1436,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.617,394.9816,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,667.663,2520.7624,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,667.663,2520.7624,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,667.663,2520.7624,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,238.419,900.1512,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,238.419,900.1512,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,238.419,900.1512,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,324.4025,1224.782,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.576,379.7248,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,77.9015,294.1172,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,239.0925,902.694,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.2485,299.2028,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,317.2185,1197.6588,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,289.605,1093.404,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,289.605,1093.404,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,479.3075,1809.626,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,167.2525,631.462,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,58.819,222.0712,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,58.819,222.0712,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.2485,299.2028,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,288.707,1090.0136,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.7005,550.0924,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,170.171,642.4808,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,238.6435,900.9988,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,245.3785,926.4268,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,273.2165,1031.5292,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,304.1975,1148.498,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,313.851,1184.9448,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,330.913,1249.3624,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,336.5255,1270.5524,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,398.0385,1502.7948,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,355.8325,1343.446,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,367.282,1386.6736,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,392.6505,1482.4524,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.413,401.7624,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.413,401.7624,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.413,401.7624,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,73.636,278.0128,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.107,411.9336,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,398.0385,1502.7948,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.803,588.2344,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.413,401.7624,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.6375,402.61,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,383.895,1449.396,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,297.9115,1124.7652,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,297.9115,1124.7652,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,291.85,1101.88,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.184,27.1232,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.879,120.3592,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,35.2465,133.0732,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.124,128.8352,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,46.696,176.3008,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.47,50.856,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.8375,63.57,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.47,50.856,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.8375,63.57,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2255,83.9124,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.43,118.664,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,30.981,116.9688,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,35.6955,134.7684,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.15,593.32,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,190.825,720.46,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,373.119,1408.7112,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,213.275,805.22,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,656.438,2478.3824,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,269.4,1017.12,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,956.819,3612.4712,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2057.767,7769.1016,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,269.4,1017.12,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,841.6505,3177.6524,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1202.422,4539.7456,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2164.4045,8171.7116,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.6125,21.19,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.939,18.6472,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.1635,19.4948,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.286,23.7328,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.5105,24.5804,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.4085,27.9708,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.531,32.2088,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,336.75,1271.4,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.6745,6652,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.7405,482.2844,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.7405,482.2844,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.5105,24.5804,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.5715,163,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.6535,163,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,38.3895,163,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9291.52,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6297.984,,
Heart Transplant Or Implant Of Heart Assist System With McC,1,MS-DRG,,,,,,,inpatient,,,509415.58,356590.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,249067.5832,,,249067.5832,7771.48,570763.9296,case rate,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,495073.43,346551.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,189560.4996,,,189560.4996,7771.48,434261.5728,case rate,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,347238.19,243066.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,125063.5024,,,125063.5024,7771.48,286312.0824,case rate,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,111379.6,77965.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47912.84716,,,47912.84716,7771.48,109336.4384,case rate,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,80508.95,56356.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39754.43987,,,39754.43987,7771.48,90620.608,case rate,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,64638.3,45246.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,53951.26988,,,53951.26988,7771.48,123186.8824,case rate,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,31748.36,22223.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29900.04491,,,29900.04491,7771.48,68016.116,case rate,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,38853.43,27197.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19906.96764,,,19906.96764,7771.48,45091.4528,case rate,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,36305.14,25413.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14342.89147,,,14342.89147,7771.48,32329.1856,case rate,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,66447.77,46513.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34599.34405,,,34599.34405,7771.48,78796.564,case rate,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,67076.27,46953.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20343.33113,,,20343.33113,7771.48,53661.016,case rate,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,60360.78,42252.546,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16441.67619,,,16441.67619,7771.48,48288.624,case rate,
Extracranial Procedures With McC,37,MS-DRG,,,,,,,inpatient,,,89958.63,62971.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29583.81388,,,29583.81388,7771.48,71966.904,case rate,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,41578.78,29105.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14482.45712,,,14482.45712,7771.48,33263.024,case rate,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,33795.18,23656.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10303.43753,,,10303.43753,7771.48,27036.144,case rate,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,68215.86,47751.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20196.69887,,,20196.69887,7771.48,54572.688,case rate,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,26930.4,18851.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13491.36433,,,13491.36433,7771.48,30377.7624,case rate,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,21358.75,14951.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9886.507232,,,9886.507232,7123.143125,22105.9976,case rate,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,44783.08,31348.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22368.79972,,,22368.79972,7771.48,50741.056,case rate,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,47305.96,33114.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12036.52492,,,12036.52492,7771.48,37844.768,case rate,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,15006.39,10504.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16554.74204,,,16554.74204,5004.631065,37401.2648,case rate,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,24159.04,16911.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11057.79871,,,11057.79871,7771.48,24793.004,case rate,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,28159.44,19711.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8132.219999,,,8132.219999,6624.72,22527.552,case rate,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,89978.5,62984.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,24129.27025,,,24129.27025,7771.48,71982.8,case rate,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,41764.16,29234.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15980.57955,,,15980.57955,7771.48,36086.1312,case rate,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,42817.54,29972.278,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12658.38706,,,12658.38706,7771.48,34254.032,case rate,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,29171.68,20420.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17820.54949,,,17820.54949,7771.48,40307.1224,case rate,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20113.63,14079.541,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9231.961995,,,9231.961995,6707.895605,20608.488,case rate,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,15729.11,11010.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6329.349786,,,6329.349786,5143.64,13947.7112,case rate,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,46442.5,32509.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13100.93384,,,13100.93384,7771.48,37154,case rate,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,28051.55,19636.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8035.937366,,,8035.937366,6429.37,22441.24,case rate,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17263.03,12084.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7316.909266,,,7316.909266,5687.74,16215.2528,case rate,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,34983.65,24488.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15608.69892,,,15608.69892,7771.48,35233.0168,case rate,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,19683.37,13778.359,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9558.79295,,,9558.79295,6564.403895,21354.2032,case rate,
Nonspecific Cerebrovascular Disorders Without Cc/McC,72,MS-DRG,,,,,,,inpatient,,,12084.89,8459.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6876.12914,,,6876.12914,4030.310815,15200.0264,case rate,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,16388.09,11471.663,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13902.11134,,,13902.11134,5465.428015,31318.012,case rate,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,28055.14,19638.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9457.210356,,,9457.210356,7368.52,22444.112,case rate,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,26116.94,18281.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8348.635091,,,8348.635091,7097.19,20893.552,case rate,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,23235.5,16264.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13908.29463,,,13908.29463,7749.03925,31332.1968,case rate,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,15869.98,11108.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9064.129883,,,9064.129883,5292.63833,20219.4192,case rate,
Hypertensive Encephalopathy Without Cc/McC,79,MS-DRG,,,,,,,inpatient,,,15211.5,10648.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6138.551175,,,6138.551175,5073.03525,13510.0088,case rate,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,53186.54,37230.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17808.18291,,,17808.18291,7771.48,42549.232,case rate,
Nontraumatic Stupor And Coma Without McC,81,MS-DRG,,,,,,,inpatient,,,72271.24,50589.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8241.752535,,,8241.752535,5585.72,57816.992,case rate,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,28572.47,20000.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20744.36155,,,20744.36155,7771.48,47014.5064,case rate,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,30376.08,21263.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12531.18798,,,12531.18798,7771.48,28173.0392,case rate,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,15324.04,10726.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8694.899237,,,8694.899237,5110.56734,19372.384,case rate,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,40898.43,28628.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20265.59836,,,20265.59836,7771.48,45916.1976,case rate,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,13317.55,9322.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11835.12638,,,11835.12638,4441.402925,26578.2624,case rate,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,24255.02,16978.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8058.020539,,,8058.020539,6241.25,19404.016,case rate,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,42230.83,29561.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16351.57685,,,16351.57685,7771.48,36937.2192,case rate,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,30155.68,21108.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9601.192642,,,9601.192642,7134.82,24124.544,case rate,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,16152.97,11307.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7221.50996,,,7221.50996,5387.015495,15994.3752,case rate,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,56481.63,39537.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32479.35948,,,32479.35948,7771.48,73931.1776,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,49973.83,34981.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31913.14693,,,31913.14693,7771.48,72642.3872,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,15617.77,10932.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19411.42125,,,19411.42125,5208.526295,43954.6424,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC,99,MS-DRG,,,,,,,inpatient,,,27081.74,18957.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12556.80447,,,12556.80447,7771.48,28231.8048,case rate,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,34012.87,23809.009,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17786.09974,,,17786.09974,7771.48,40228.0928,case rate,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,18803.33,13162.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8391.034782,,,8391.034782,6270.910555,18675.3024,case rate,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,27377.14,19163.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10491.58616,,,10491.58616,7771.48,23494.0816,case rate,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,23893.76,16725.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7759.456045,,,7759.456045,5992.35,19115.008,case rate,
Acute Major Eye Infections With Cc/McC,121,MS-DRG,,,,,,,inpatient,,,20815.14,14570.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10524.26926,,,10524.26926,6941.84919,23569.0584,case rate,
Acute Major Eye Infections Without Cc/McC,122,MS-DRG,,,,,,,inpatient,,,8234.57,5764.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6241.017096,,,6241.017096,2746.229095,13745.0712,case rate,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,28026.78,19618.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7344.2924,,,7344.2924,5537.24,22421.424,case rate,
Other Disorders Of The Eye With McC Or Thrombolytic Agent,124,MS-DRG,,,,,,,inpatient,,,12298.33,8608.831,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11767.11021,,,11767.11021,4101.493055,26420.2032,case rate,
Other Disorders Of The Eye Without McC,125,MS-DRG,,,,,,,inpatient,,,18740.93,13118.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7543.040953,,,7543.040953,6044.44,16731.9848,case rate,
Mouth Procedures With Cc/McC,137,MS-DRG,,,,,,,inpatient,,,29533.69,20673.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12603.62079,,,12603.62079,7771.48,28339.204,case rate,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,44941.05,31458.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29415.98177,,,29415.98177,7771.48,66905.6488,case rate,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,9316.44,6521.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15766.81444,,,15766.81444,3107.03274,35595.7424,case rate,
Ear- Nose- Mouth And Throat Malignancy With McC,146,MS-DRG,,,,,,,inpatient,,,13156.92,9209.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20513.81322,,,20513.81322,4387.83282,46483.5896,case rate,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,13619.01,9533.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6852.279314,,,6852.279314,4541.939835,15147.34,case rate,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,14296.01,10007.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6945.028639,,,6945.028639,4767.719335,15360.112,case rate,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,12866.36,9006.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10273.40442,,,10273.40442,4290.93106,22993.5608,case rate,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,16420.88,11494.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6536.048282,,,6536.048282,5141.47,14421.8888,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,12009,8406.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14614.95615,,,14614.95615,4005.0015,32953.3168,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,39912.51,27938.757,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8496.150684,,,8496.150684,6561.05,31930.008,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,11067.63,7747.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6188.900808,,,6188.900808,3691.054605,13625.5136,case rate,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,32953.66,23067.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14713.88877,,,14713.88877,7771.48,33180.2736,case rate,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,27223.03,19056.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8557.983567,,,8557.983567,6432.99,21778.424,case rate,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,2839.79,1987.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6075.834964,,,6075.834964,947.069965,13366.1344,case rate,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,115551.53,80886.071,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,40963.7144,,,40963.7144,7771.48,93394.7496,case rate,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,85038.13,59526.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22482.74889,,,22482.74889,7771.48,68030.504,case rate,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,69826.08,48878.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16714.62421,,,16714.62421,7771.48,55860.864,case rate,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,55683.12,38978.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34260.14652,,,34260.14652,7771.48,78036.664,case rate,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,45649.7,31954.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16389.55991,,,16389.55991,7771.48,37024.3544,case rate,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,47015.57,32910.899,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12208.77366,,,12208.77366,7771.48,37612.456,case rate,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,78265.02,54785.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27355.1801,,,27355.1801,7771.48,62612.016,case rate,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,20842.72,14589.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12696.37012,,,12696.37012,6951.04712,28554.0024,case rate,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,18317.47,12822.229,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7444.10834,,,7444.10834,6108.876245,16505.028,case rate,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,31259.62,21881.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14528.39012,,,14528.39012,7771.48,32756.756,case rate,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,20969.38,14678.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9012.896923,,,9012.896923,6993.28823,20103.9144,case rate,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20162.41,14113.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7048.377887,,,7048.377887,6302.75,16129.928,case rate,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,37050.11,25935.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15688.19834,,,15688.19834,7771.48,35415.3928,case rate,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,30930.47,21651.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10056.98932,,,10056.98932,7771.48,24744.376,case rate,
Respiratory Neoplasms Without Cc/McC,182,MS-DRG,,,,,,,inpatient,,,24638.57,17246.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7647.273528,,,7647.273528,5697.87,19710.856,case rate,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,35855.45,25098.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14270.45866,,,14270.45866,7771.48,32163.0208,case rate,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,22588.59,15812.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9684.225371,,,9684.225371,7520.46,21641.952,case rate,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,25741.06,18018.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14205.9758,,,14205.9758,7771.48,32017.12,case rate,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,11443.72,8010.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9118.012825,,,9118.012825,3816.48062,20343.0296,case rate,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,21611.05,15127.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11179.69782,,,11179.69782,7207.285175,25076.7,case rate,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,22710.76,15897.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10169.17184,,,10169.17184,7574.03846,22762.5512,case rate,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,17567.6,12297.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7838.07214,,,7838.07214,5858.7946,17408.8024,case rate,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,13024.23,9116.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5966.302428,,,5966.302428,4343.580705,13114.8608,case rate,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,25981.01,18186.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11889.00933,,,11889.00933,7771.48,26703.8992,case rate,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,18230.9,12761.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7492.69132,,,7492.69132,6080.00515,16616.48,case rate,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,12094.06,8465.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5749.887336,,,5749.887336,4033.36901,12620.4192,case rate,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25422.94,17796.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16892.17291,,,16892.17291,7771.48,38181.4288,case rate,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,23032.67,16122.869,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8994.347058,,,8994.347058,7275.91,20059.3336,case rate,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,22301.78,15611.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15842.78055,,,15842.78055,7437.64363,35770.0128,case rate,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,31940.04,22358.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10032.25617,,,10032.25617,7771.48,25552.032,case rate,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,17352.2,12146.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6230.417173,,,6230.417173,5133.51,13881.76,case rate,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,17596.96,12317.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8788.531889,,,8788.531889,5868.58616,19589.2088,case rate,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,12229.54,8560.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6402.665919,,,6402.665919,4078.55159,14109.8232,case rate,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,30544.64,21381.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7413.191898,,,7413.191898,5734.05,24435.712,case rate,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,23745.99,16622.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16924.85601,,,16924.85601,7771.48,38252.3528,case rate,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,17630.01,12341.007,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8250.585804,,,8250.585804,5879.608335,18355.1312,case rate,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,173078.09,121154.663,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,57375.92829,,,57375.92829,7771.48,138462.472,case rate,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,53859.21,37701.447,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23956.13817,,,23956.13817,7771.48,54390.6024,case rate,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,inpatient,,,221306.62,154914.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,96478.16039,,,96478.16039,7771.48,220737.7784,case rate,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,354301.39,248010.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,93836.12961,,,93836.12961,7771.48,283441.112,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC,216,MS-DRG,,,,,,,inpatient,,,299760.69,209832.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,85500.17361,,,85500.17361,7771.48,239808.552,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,inpatient,,,204620.11,143234.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,57293.77889,,,57293.77889,7771.48,163696.088,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC,219,MS-DRG,,,,,,,inpatient,,,208854.44,146198.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,68596.82996,,,68596.82996,7771.48,167083.552,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,inpatient,,,154365.68,108055.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47036.58687,,,47036.58687,7771.48,123492.544,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,181781.45,127247.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,40817.08213,,,40817.08213,7771.48,145425.16,case rate,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,228758.84,160131.188,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,44268.24035,,,44268.24035,7771.48,183007.072,case rate,
Other Cardiothoracic Procedures Without McC,229,MS-DRG,,,,,,,inpatient,,,95347.28,66743.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27688.19435,,,27688.19435,7771.48,76277.824,case rate,
Coronary Bypass With Ptca With McC,231,MS-DRG,,,,,,,inpatient,,,220697.29,154488.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,75101.64929,,,75101.64929,7771.48,176557.832,case rate,
Coronary Bypass With Ptca Without McC,232,MS-DRG,,,,,,,inpatient,,,203083.55,142158.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,54209.20134,,,54209.20134,7771.48,162466.84,case rate,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,193515.4,135460.78,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,69293.77489,,,69293.77489,7771.48,158379.3712,case rate,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,165546.93,115882.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47244.16869,,,47244.16869,7771.48,132437.544,case rate,
Coronary Bypass Without Cardiac Catheterization With McC,235,MS-DRG,,,,,,,inpatient,,,145342.16,101739.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,52226.13243,,,52226.13243,7771.48,119229.3232,case rate,
Coronary Bypass Without Cardiac Catheterization Without McC,236,MS-DRG,,,,,,,inpatient,,,130227.12,91158.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36572.69635,,,36572.69635,7771.48,104181.696,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,39344.02,27540.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,44741.70357,,,44741.70357,7771.48,102059.636,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,41409.42,28986.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25973.65682,,,25973.65682,7771.48,59008.768,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC,241,MS-DRG,,,,,,,inpatient,,,19499.72,13649.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13586.76364,,,13586.76364,6503.15662,30594.5872,case rate,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,76706.54,53694.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30211.85931,,,30211.85931,7771.48,68735.488,case rate,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,63602.84,44521.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20148.99921,,,20148.99921,7771.48,50882.272,case rate,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,60755.43,42528.801,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16190.81135,,,16190.81135,7771.48,48604.344,case rate,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,109531.23,76671.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43415.82989,,,43415.82989,7771.48,99020.036,case rate,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC,250,MS-DRG,,,,,,,inpatient,,,42609.28,29826.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20677.2287,,,20677.2287,7771.48,46864.5528,case rate,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,52812.94,36969.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14052.27692,,,14052.27692,7771.48,42250.352,case rate,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,100566.7,70396.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30551.05684,,,30551.05684,7771.48,80453.36,case rate,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,72499.37,50749.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22800.74658,,,22800.74658,7771.48,57999.496,case rate,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,68903.94,48232.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15702.33157,,,15702.33157,7771.48,55123.152,case rate,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13134.86,9194.402,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15210.31849,,,15210.31849,4380.47581,34319.1104,case rate,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,20863.13,14604.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8127.803364,,,8127.803364,6957.853855,18073.4616,case rate,
Cardiac Pacemaker Device Replacement With McC,258,MS-DRG,,,,,,,inpatient,,,71596.9,50117.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25031.14702,,,25031.14702,7771.48,57277.52,case rate,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,44827.64,31379.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15775.64771,,,15775.64771,7771.48,35862.112,case rate,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,130030.35,91021.245,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30337.29173,,,30337.29173,7771.48,104024.28,case rate,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,49670.67,34769.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17011.42205,,,17011.42205,7771.48,39736.536,case rate,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC,262,MS-DRG,,,,,,,inpatient,,,58341.51,40839.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13656.54646,,,13656.54646,7771.48,46673.208,case rate,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,49042.27,34329.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31122.56935,,,31122.56935,7771.48,70820.6536,case rate,
Aicd Lead Procedures,265,MS-DRG,,,,,,,inpatient,,,64208.05,44945.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31759.44805,,,31759.44805,7771.48,72279.6616,case rate,
Endovascular Cardiac Valve Replacement And Supplement Procedures With McC,266,MS-DRG,,,,,,,inpatient,,,134751.65,94326.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,53167.75892,,,53167.75892,7771.48,121389.4656,case rate,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC,267,MS-DRG,,,,,,,inpatient,,,133372.27,93360.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41807.29159,,,41807.29159,7771.48,106697.816,case rate,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,241728.99,169210.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,59146.11541,,,59146.11541,7771.48,193383.192,case rate,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,132639.05,92847.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37001.99323,,,37001.99323,7771.48,106111.24,case rate,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,135782.35,95047.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,45590.58073,,,45590.58073,7771.48,108625.88,case rate,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,140000.81,98000.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30674.72261,,,30674.72261,7771.48,112000.648,case rate,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,151532.98,106073.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22352.01651,,,22352.01651,7771.48,121226.384,case rate,
Percutaneous And Other Intracardiac Procedures With McC,273,MS-DRG,,,,,,,inpatient,,,102782.81,71947.967,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34790.14266,,,34790.14266,7771.48,82226.248,case rate,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,82201.95,57541.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27818.0434,,,27818.0434,7771.48,65761.56,case rate,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,183325.52,128327.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,62674.12307,,,62674.12307,7771.48,146660.416,case rate,
Cardiac Defibrillator Implant With McC,276,MS-DRG,,,,,,,inpatient,,,196887.28,137821.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,54966.21249,,,54966.21249,7771.48,157509.824,case rate,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,177791.04,124453.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41340.89499,,,41340.89499,7771.48,142232.832,case rate,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,157626.97,110338.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,44444.90573,,,44444.90573,7771.48,126101.576,case rate,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,93744.91,65621.437,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28554.73804,,,28554.73804,7771.48,74995.928,case rate,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31041.23,21728.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14748.33852,,,14748.33852,7771.48,33263.356,case rate,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,26543.44,18580.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8391.918109,,,8391.918109,6744.11,21234.752,case rate,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,23815.3,16670.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6654.414087,,,6654.414087,5249.28,19052.24,case rate,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,19212.47,13448.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17521.985,,,17521.985,6407.358745,39624.2256,case rate,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,10954.07,7667.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6794.863065,,,6794.863065,3653.182345,15013.5976,case rate,
Acute Myocardial Infarction- Expired Without Cc/McC,285,MS-DRG,,,,,,,inpatient,,,7163.26,5014.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5208.407944,,,5208.407944,2388.94721,11374.1832,case rate,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,38892.53,27224.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19800.08508,,,19800.08508,7771.48,44850.3112,case rate,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,30727.74,21509.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9875.023982,,,9875.023982,7771.48,24582.192,case rate,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,28457.96,19920.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,24377.48511,,,24377.48511,7771.48,55347.0632,case rate,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,19767.12,13836.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14176.82601,,,14176.82601,6592.33452,31948.2224,case rate,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,20727.01,14508.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11775.06015,,,11775.06015,6912.457835,26442.4936,case rate,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,15225.15,10657.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7856.622005,,,7856.622005,5077.587525,17453.3832,case rate,
Heart Failure And Shock Without Cc/McC,293,MS-DRG,,,,,,,inpatient,,,10124.22,7086.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5096.225427,,,5096.225427,3376.42737,11124.936,case rate,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,25950.27,18165.189,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14721.83871,,,14721.83871,7771.48,33198.5112,case rate,
Cardiac Arrest- Unexplained With Cc,297,MS-DRG,,,,,,,inpatient,,,10642.36,7449.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6471.565418,,,6471.565418,3549.22706,14273.9616,case rate,
Cardiac Arrest- Unexplained Without Cc/McC,298,MS-DRG,,,,,,,inpatient,,,12953.57,9067.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4151.065639,,,4151.065639,4151.065639,10362.856,case rate,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,22073.95,15451.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14538.10671,,,14538.10671,7361.662325,32781.0728,case rate,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,21942.88,15360.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9706.308543,,,9706.308543,7317.95048,21692.612,case rate,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,24649.73,17254.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6551.064839,,,6551.064839,5372.28,19719.784,case rate,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,9953.04,6967.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10525.15258,,,10525.15258,3319.33884,23571.0848,case rate,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16791.27,11753.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6188.900808,,,6188.900808,4894.02,13625.5136,case rate,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,37676.15,26373.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10626.73518,,,10626.73518,7771.48,30140.92,case rate,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,16488.7,11542.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6880.545775,,,6880.545775,5343.34,15212.1848,case rate,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,22172.6,15520.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13476.34777,,,13476.34777,7394.5621,30343.3136,case rate,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,15582.95,10908.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8432.551146,,,8432.551146,5196.913825,18770.5432,case rate,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,19410.63,13587.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10901.44985,,,10901.44985,6473.445105,24438.384,case rate,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,14290.45,10003.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6779.846508,,,6779.846508,4765.865075,14981.1752,case rate,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,11407.4,7985.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5191.624733,,,5191.624733,3804.3679,11337.708,case rate,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,11897.35,8328.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6417.682477,,,6417.682477,3967.766225,14154.404,case rate,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,16541.17,11578.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7945.838022,,,7945.838022,5516.480195,17656.0232,case rate,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,15084.64,10559.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6551.064839,,,6551.064839,5030.72744,14454.3112,case rate,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,31164.15,21814.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19271.8556,,,19271.8556,7771.48,43636.4976,case rate,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,18201.8,12741.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8749.665505,,,8749.665505,6070.3003,19500.0472,case rate,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,10045.09,7031.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6279.883479,,,6279.883479,3350.037515,13832.2064,case rate,
Other Endovascular Cardiac Valve Procedures With McC,319,MS-DRG,,,,,,,inpatient,,,92577.92,64804.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39052.19498,,,39052.19498,7771.48,89009.62,case rate,
Other Endovascular Cardiac Valve Procedures Without McC,320,MS-DRG,,,,,,,inpatient,,,39673.91,27771.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20696.66189,,,20696.66189,7771.48,46903.0544,case rate,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,92249.33,64574.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25395.96103,,,25395.96103,7771.48,73799.464,case rate,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,75877.65,53114.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16230.56106,,,16230.56106,7771.48,60702.12,case rate,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,116736.51,81715.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37873.83688,,,37873.83688,7771.48,93389.208,case rate,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,126333.04,88433.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28472.58864,,,28472.58864,7771.48,101066.432,case rate,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,inpatient,,,98701.5,69091.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25531.11004,,,25531.11004,7771.48,78961.2,case rate,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,64991.97,45494.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,45113.5842,,,45113.5842,7771.48,102914.7768,case rate,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,59110.49,41377.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21697.47128,,,21697.47128,7771.48,49203.0184,case rate,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,49561.22,34692.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14325.22493,,,14325.22493,7771.48,39648.976,case rate,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,78913.19,55239.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,40810.89884,,,40810.89884,7771.48,93046.2088,case rate,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,69586.46,48710.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21128.60875,,,21128.60875,7771.48,55669.168,case rate,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,57546.85,40282.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14833.1379,,,14833.1379,7771.48,46037.48,case rate,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,97325,68127.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19022.75741,,,19022.75741,7771.48,77860,case rate,
Rectal Resection Without Cc/McC,334,MS-DRG,,,,,,,inpatient,,,106215.45,74350.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14900.27074,,,14900.27074,7771.48,84972.36,case rate,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,73034.84,51124.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32255.87777,,,32255.87777,7771.48,73434.7096,case rate,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,43630.89,30541.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18907.92491,,,18907.92491,7771.48,42805.6736,case rate,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,37370.19,26159.133,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13809.36202,,,13809.36202,7771.48,31105.24,case rate,
Minor Small And Large Bowel Procedures With McC,344,MS-DRG,,,,,,,inpatient,,,23852.76,16696.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,24050.65415,,,24050.65415,7771.48,54599.3216,case rate,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,15908.61,11136.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13399.49833,,,13399.49833,5305.521435,30177.1488,case rate,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,21216.99,14851.893,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11249.48065,,,11249.48065,7075.866165,25232.7328,case rate,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,44922.74,31445.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21155.99188,,,21155.99188,7771.48,47956.7824,case rate,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,23475.59,16432.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11369.61311,,,11369.61311,7771.48,25508.3232,case rate,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,34354.1,24047.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13539.06398,,,13539.06398,7771.48,30491.2408,case rate,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,42230.08,29561.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9988.973153,,,9988.973153,7771.48,33784.064,case rate,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,312395.2,218676.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26157.38882,,,26157.38882,7771.48,249916.16,case rate,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,44235.04,30964.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15275.68468,,,15275.68468,7771.48,35388.032,case rate,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,51507.45,36055.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12025.925,,,12025.925,7771.48,41205.96,case rate,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,70735.47,49514.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37929.48648,,,37929.48648,7771.48,86434.0656,case rate,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,77577.93,54304.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20141.9326,,,20141.9326,7771.48,62062.344,case rate,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,27080.24,18956.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12219.37359,,,12219.37359,7771.48,27457.72,case rate,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,23431.55,16402.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15000.97001,,,15000.97001,7771.48,33838.8536,case rate,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,31489.94,22042.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9238.145284,,,9238.145284,7771.48,25191.952,case rate,
Major Esophageal Disorders Without Cc/McC,370,MS-DRG,,,,,,,inpatient,,,29793.71,20855.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6415.032496,,,6415.032496,5409.18,23834.968,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,37215.27,26050.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15689.965,,,15689.965,7771.48,35427.5512,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,24764.87,17335.409,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9341.494532,,,9341.494532,7435.09,20857.7352,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,19807.89,13865.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6657.064068,,,6657.064068,5379.51,15846.312,case rate,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,38795.7,27156.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18899.97497,,,18899.97497,7771.48,42787.436,case rate,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,40108.1,28075.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11102.84838,,,11102.84838,7771.48,32086.48,case rate,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,8031.54,5622.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8049.18727,,,8049.18727,2678.51859,17891.0856,case rate,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,38252.31,26776.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16310.06048,,,16310.06048,7771.48,36841.9784,case rate,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,30659.48,21461.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8958.130655,,,8958.130655,7186.19,24527.584,case rate,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,17080.5,11956.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5873.553103,,,5873.553103,4609.67,13664.4,case rate,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33361.1,23352.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17247.27033,,,17247.27033,7771.48,38994.0152,case rate,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,34876.59,24413.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9869.724021,,,9869.724021,7667.34,27901.272,case rate,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,23295.58,16306.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7930.821465,,,7930.821465,6456.86,18636.464,case rate,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,19010.83,13307.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14601.70625,,,14601.70625,6340.111805,32922.9208,case rate,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,17687.57,12381.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9016.430231,,,9016.430231,5898.804595,20109.9936,case rate,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12268.03,8587.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6170.350943,,,6170.350943,4091.388005,13582.9592,case rate,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,35037.99,24526.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13233.43287,,,13233.43287,7771.48,29788.08,case rate,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,19193.48,13435.436,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7330.159169,,,7330.159169,5946.04,16245.6488,case rate,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12403.72,8682.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5082.975523,,,5082.975523,4136.64062,11086.4344,case rate,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,23697.98,16588.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11595.74479,,,11595.74479,7771.48,26037.2136,case rate,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16680.62,11676.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7142.010538,,,7142.010538,5530.73,15811.9992,case rate,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,35226.46,24658.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14877.30424,,,14877.30424,7771.48,33555.1576,case rate,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,21027.93,14719.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8564.166855,,,8564.166855,6791.14,19074.5032,case rate,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,19292.51,13504.757,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5870.903122,,,5870.903122,4700.83,15434.008,case rate,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,31379.86,21965.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22136.48475,,,22136.48475,7771.48,50206.0864,case rate,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,37379.45,26165.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13615.91342,,,13615.91342,7771.48,30665.5112,case rate,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,31865.55,22305.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10176.23846,,,10176.23846,7771.48,25492.44,case rate,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,43167.44,30217.208,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25056.7635,,,25056.7635,7771.48,56905.3648,case rate,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,37981.98,26587.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19115.50673,,,19115.50673,7771.48,43275.7984,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC,408,MS-DRG,,,,,,,inpatient,,,66496.81,46547.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31177.33562,,,31177.33562,7771.48,70946.2904,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,54723.42,38306.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18768.35926,,,18768.35926,7771.48,43778.736,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC,410,MS-DRG,,,,,,,inpatient,,,49332.9,34533.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13950.69432,,,13950.69432,7771.48,39466.32,case rate,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,inpatient,,,94854.82,66398.374,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19078.407,,,19078.407,7771.48,75883.856,case rate,
Cholecystectomy Except By Laparoscope Without C.D.E. With McC,414,MS-DRG,,,,,,,inpatient,,,158479.92,110935.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31199.41879,,,31199.41879,7771.48,126783.936,case rate,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/McC,416,MS-DRG,,,,,,,inpatient,,,36054.28,25237.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12352.75595,,,12352.75595,7771.48,28843.424,case rate,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,57775.9,40443.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21241.67459,,,21241.67459,7771.48,48157.396,case rate,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,45650.74,31955.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14898.50409,,,14898.50409,7771.48,36520.592,case rate,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,40583.9,28408.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11888.126,,,11888.126,7771.48,32467.12,case rate,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,43141.15,30198.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31426.43381,,,31426.43381,7771.48,71515.7088,case rate,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,126455.95,88519.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36177.84923,,,36177.84923,7771.48,101164.76,case rate,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,inpatient,,,66431.87,46502.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20418.41392,,,20418.41392,7771.48,53145.496,case rate,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,37750.2,26425.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17554.66809,,,17554.66809,7771.48,39699.2024,case rate,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,22206.74,15544.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9699.241928,,,9699.241928,7405.94779,21676.4008,case rate,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,9888.24,6921.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6401.782592,,,6401.782592,3297.72804,14111.8496,case rate,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41222.48,28855.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16366.59341,,,16366.59341,7771.48,36971.668,case rate,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,21857.06,15299.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10210.68821,,,10210.68821,7289.32951,22849.6864,case rate,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,34142.65,23899.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14945.32042,,,14945.32042,7771.48,33715.2432,case rate,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,18774.77,13142.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7847.788735,,,7847.788735,6109.56,17431.0928,case rate,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,12926.06,9048.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5682.754492,,,5682.754492,4310.84101,12464.3864,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,33617.1,23531.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16947.82251,,,16947.82251,7771.48,38305.0392,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,18826.25,13178.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8784.115255,,,8784.115255,6278.554375,19579.0768,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,9263.58,6484.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6456.54886,,,6456.54886,3089.40393,14237.4864,case rate,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,36248.92,25374.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15128.16909,,,15128.16909,7771.48,34134.708,case rate,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,33226.4,23258.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9829.090983,,,9829.090983,7771.48,26581.12,case rate,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,28308.58,19816.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7292.176112,,,7292.176112,5905.53,22646.864,case rate,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With McC,456,MS-DRG,,,,,,,inpatient,,,202351.8,141646.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,75060.13292,,,75060.13292,7771.48,171607.7104,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,70294.35,49206.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47957.89683,,,47957.89683,7771.48,109439.7848,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,25826.71,18078.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26295.18782,,,26295.18782,7771.48,59750.4304,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,10589.98,7412.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15584.84909,,,15584.84909,3531.75833,35176.2776,case rate,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,134518.68,94163.076,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,45251.38319,,,45251.38319,7771.48,107614.944,case rate,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,95919.47,67143.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30505.12384,,,30505.12384,7771.48,76735.576,case rate,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,68797.87,48158.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23421.72539,,,23421.72539,7771.48,55038.296,case rate,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,54280.26,37996.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29122.71724,,,29122.71724,7771.48,66232.884,case rate,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,53419.21,37393.447,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16904.53949,,,16904.53949,7771.48,42735.368,case rate,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68987.67,48291.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43155.24845,,,43155.24845,7771.48,98422.248,case rate,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,77778.52,54444.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25841.15779,,,25841.15779,7771.48,62222.816,case rate,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,54869.65,38408.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21161.29185,,,21161.29185,7771.48,47968.9408,case rate,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,71787.88,50251.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39863.9724,,,39863.9724,7771.48,90871.8816,case rate,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,33747.79,23623.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19305.42202,,,19305.42202,7771.48,43711.4744,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,89768.8,62838.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30627.02296,,,30627.02296,7771.48,71815.04,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,65676.03,45973.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20906.8937,,,20906.8937,7771.48,52540.824,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,26493.14,18545.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15935.52988,,,15935.52988,7771.48,35982.7848,case rate,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,50028.86,35020.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26228.05497,,,26228.05497,7771.48,59596.424,case rate,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,54052.44,37836.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18577.56065,,,18577.56065,7771.48,43241.952,case rate,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,42724.18,29906.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14262.50872,,,14262.50872,7771.48,34179.344,case rate,
Knee Procedures With Principal Diagnosis Of Infection With McC,485,MS-DRG,,,,,,,inpatient,,,78688.59,55082.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28686.35375,,,28686.35375,7771.48,65323.0304,case rate,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,38633.42,27043.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18983.89102,,,18983.89102,7771.48,42973.8648,case rate,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,68635.57,48044.899,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17610.31769,,,17610.31769,7771.48,54908.456,case rate,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,35436.81,24805.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11188.53109,,,11188.53109,7771.48,28349.448,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,77413.36,54189.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31618.11574,,,31618.11574,7771.48,71957.464,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,79988.8,55992.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21458.08969,,,21458.08969,7771.48,63991.04,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,52007.74,36405.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16903.65616,,,16903.65616,7771.48,41606.192,case rate,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC,495,MS-DRG,,,,,,,inpatient,,,55215.82,38651.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31347.81771,,,31347.81771,7771.48,71335.3592,case rate,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC,499,MS-DRG,,,,,,,inpatient,,,24343.66,17040.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10503.06941,,,10503.06941,7771.48,23522.4512,case rate,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,43692.12,30584.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28239.39033,,,28239.39033,7771.48,64206.484,case rate,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,30673.94,21471.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16014.14597,,,16014.14597,7771.48,36169.2136,case rate,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,41306.96,28914.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23627.54056,,,23627.54056,7771.48,53628.676,case rate,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,37180.29,26026.203,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15751.79788,,,15751.79788,7771.48,35575.4784,case rate,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,63266.34,44286.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17370.05277,,,17370.05277,7771.48,50613.072,case rate,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,57782.59,40447.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25495.77697,,,25495.77697,7771.48,57914.512,case rate,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,39749.27,27824.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17573.21796,,,17573.21796,7771.48,39745.8096,case rate,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,26213.06,18349.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13548.78058,,,13548.78058,7771.48,30507.452,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,64680.35,45276.245,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27565.41191,,,27565.41191,7771.48,62660.3408,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,33187.16,23231.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18019.29804,,,18019.29804,7771.48,40763.0624,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,28664.41,20065.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13434.83141,,,13434.83141,7771.48,30246.0464,case rate,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,52006.98,36404.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31907.84697,,,31907.84697,7771.48,72622.1232,case rate,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,60945.78,42662.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17667.73394,,,17667.73394,7771.48,48756.624,case rate,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,27733.63,19413.541,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12909.2519,,,12909.2519,7771.48,29040.3384,case rate,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,64155.47,44908.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25995.74,,,25995.74,7771.48,59061.4544,case rate,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59467.45,41627.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18870.82518,,,18870.82518,7771.48,47573.96,case rate,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,24348.24,17043.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11996.77521,,,11996.77521,7771.48,26949.0936,case rate,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,14748.61,10324.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7412.308571,,,7412.308571,4918.661435,16432.0776,case rate,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,34525.72,24168.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18113.81402,,,18113.81402,7771.48,40987.9928,case rate,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,27528.18,19269.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11680.54418,,,11680.54418,7771.48,26229.7216,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,28046.03,19632.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16724.3408,,,16724.3408,7771.48,37790.3336,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,29133.49,20393.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9620.625833,,,9620.625833,7548.68,23306.792,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,17251.52,12076.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6924.71212,,,6924.71212,5616.11,15313.5048,case rate,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,10607.77,7425.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22570.19826,,,22570.19826,3537.691295,51201.0488,case rate,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,22929.4,16050.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10475.68628,,,10475.68628,7646.9549,23459.6328,case rate,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,15898.64,11129.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6840.796064,,,6840.796064,5302.19644,15120.9968,case rate,
Septic Arthritis Without Cc/McC,550,MS-DRG,,,,,,,inpatient,,,13751.03,9625.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7864.571947,,,7864.571947,4585.968505,17469.5944,case rate,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,34050.51,23835.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15322.501,,,15322.501,7771.48,34576.4632,case rate,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,21070.26,14749.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8762.915409,,,8762.915409,6815.74,19530.4432,case rate,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,37105.01,25973.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11785.66008,,,11785.66008,7771.48,29684.008,case rate,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,33214.93,23250.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7621.657048,,,7621.657048,5718.85,26571.944,case rate,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC,555,MS-DRG,,,,,,,inpatient,,,16910.44,11837.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12144.2908,,,12144.2908,5639.63174,27285.476,case rate,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,38978.42,27284.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7461.774878,,,7461.774878,5833.89,31182.736,case rate,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,25775.81,18043.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13938.32774,,,13938.32774,7771.48,31403.1208,case rate,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,17322.32,12125.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7879.588504,,,7879.588504,5776.99372,17504.0432,case rate,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,46066.43,32246.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16646.60803,,,16646.60803,7771.48,37612.0104,case rate,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,43659.99,30561.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10307.85417,,,10307.85417,7771.48,34927.992,case rate,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,35419.71,24793.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7471.491474,,,7471.491474,5723.92,28335.768,case rate,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,23360.4,16352.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13176.89995,,,13176.89995,7771.48,29660.4168,case rate,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,23376.03,16363.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8144.586575,,,8144.586575,6300.58,18700.824,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,24152.97,16907.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14110.57649,,,14110.57649,7771.48,31798.2688,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,26103.05,18272.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9256.695149,,,9256.695149,7280.97,20882.44,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,12203.73,8542.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6857.579275,,,6857.579275,4069.943955,15157.472,case rate,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,58121.61,40685.127,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26839.31719,,,26839.31719,7771.48,61002.7456,case rate,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,22908.56,16035.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15038.95307,,,15038.95307,7640.00476,33938.1472,case rate,
Skin Debridement Without Cc/McC,572,MS-DRG,,,,,,,inpatient,,,34042.21,23829.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10340.53726,,,10340.53726,7771.48,27233.768,case rate,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,40320.12,28224.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,54646.44815,,,54646.44815,7771.48,124781.6592,case rate,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,31675.49,22172.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30855.80463,,,30855.80463,7771.48,70208.6808,case rate,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC,575,MS-DRG,,,,,,,inpatient,,,33248.67,23274.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17886.79901,,,17886.79901,7771.48,40457.076,case rate,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,inpatient,,,22694.73,15886.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23770.63952,,,23770.63952,7568.692455,53954.9264,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,47774,33441.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29040.56784,,,29040.56784,7771.48,66042.4024,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,21385.31,14969.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15910.79672,,,15910.79672,7132.000885,35926.0456,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,107178.51,75024.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12962.25151,,,12962.25151,7771.48,85742.808,case rate,
Breast Biopsy- Local Excision And Other Breast Procedures Without Cc/McC,585,MS-DRG,,,,,,,inpatient,,,37278.64,26095.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17784.33309,,,17784.33309,7771.48,40224.04,case rate,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,53897.07,37727.949,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18413.26184,,,18413.26184,7771.48,43117.656,case rate,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,22540.18,15778.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7746.206141,,,7746.206141,5923.61,18032.144,case rate,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,26958.01,18870.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9799.057868,,,9799.057868,7157.25,21905.384,case rate,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,36927.76,25849.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15766.81444,,,15766.81444,7771.48,35593.716,case rate,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,9105.56,6373.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9779.624676,,,9779.624676,3036.70426,21862.8296,case rate,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,5148.62,3604.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5544.955495,,,5544.955495,1717.06477,12148.268,case rate,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,21201.17,14840.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13227.24959,,,13227.24959,7070.590195,29775.9216,case rate,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,14711.96,10298.372,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8029.754078,,,8029.754078,4906.43866,17850.5576,case rate,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,29329.16,20530.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13372.99853,,,13372.99853,7771.48,30106.2248,case rate,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21984.9,15389.43,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8408.70132,,,8408.70132,6578.42,18717.8568,case rate,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,26207.89,18345.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14473.62385,,,14473.62385,7771.48,32627.0664,case rate,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,18364.58,12855.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7883.121812,,,7883.121812,5973.54,17514.1752,case rate,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,63303.79,44312.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34389.99557,,,34389.99557,7771.48,78318.3336,case rate,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,33293.26,23305.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17311.75319,,,17311.75319,7771.48,39154.1008,case rate,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,inpatient,,,47713.27,33399.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14356.14137,,,14356.14137,7771.48,38170.616,case rate,
O.R. Procedures For Obesity Without Cc/McC,621,MS-DRG,,,,,,,inpatient,,,43994.97,30796.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13161.88339,,,13161.88339,7771.48,35195.976,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,22054.1,15437.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,33303.50348,,,33303.50348,7771.48,75868.416,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,19840.3,13888.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17145.68774,,,17145.68774,6616.74005,38785.296,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,624,MS-DRG,,,,,,,inpatient,,,15962.42,11173.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9110.062882,,,9110.062882,5323.46707,20326.8184,case rate,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,76735.34,53714.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35102.84038,,,35102.84038,7771.48,79967.8232,case rate,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,36824.85,25777.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20116.31612,,,20116.31612,7771.48,45596.0264,case rate,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,27285.79,19100.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13113.30042,,,13113.30042,7771.48,29510.4632,case rate,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,17323.96,12126.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8351.285071,,,8351.285071,5777.54066,18586.1408,case rate,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,11395.93,7977.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5784.337086,,,5784.337086,3800.542655,12697.4224,case rate,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,21542.6,15079.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11979.992,,,11979.992,7184.4571,26912.6184,case rate,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,14225.97,9958.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7151.727134,,,7151.727134,4744.360995,15836.316,case rate,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,13622.93,9536.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11212.38092,,,11212.38092,4543.247155,25149.6504,case rate,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,60349.49,42244.643,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14888.78749,,,14888.78749,7771.48,48279.592,case rate,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,13236.15,9265.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9377.710935,,,9377.710935,4414.256025,20942.844,case rate,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13028.88,9120.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7127.877308,,,7127.877308,4345.13148,15785.656,case rate,
Major Bladder Procedures Without Cc/McC,655,MS-DRG,,,,,,,inpatient,,,55359.22,38751.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18598.76049,,,18598.76049,7771.48,44287.376,case rate,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,47307.79,33115.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29028.20126,,,29028.20126,7771.48,66014.0328,case rate,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,42988.03,30091.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16397.50985,,,16397.50985,7771.48,37042.592,case rate,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,30491.37,21343.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23077.2279,,,23077.2279,7771.48,52366.2288,case rate,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,26889.16,18822.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12085.99122,,,12085.99122,7771.48,27151.7336,case rate,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,19523.55,13666.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9317.644705,,,9317.644705,6511.103925,20803.0224,case rate,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,57156.94,40009.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27805.67682,,,27805.67682,7771.48,63211.5216,case rate,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,29787.18,20851.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13741.34584,,,13741.34584,7771.48,30949.2072,case rate,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,15013.42,10509.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9787.574618,,,9787.574618,5006.97557,21881.0672,case rate,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,28865.76,20206.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30579.3233,,,30579.3233,7771.48,69574.4176,case rate,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,28047.28,19633.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14800.4548,,,14800.4548,7771.48,33378.8608,case rate,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,51984.11,36388.877,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26009.87323,,,26009.87323,7771.48,59091.8504,case rate,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,30494.67,21346.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13918.89455,,,13918.89455,7771.48,31358.54,case rate,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,12447.8,8713.46,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8691.36593,,,8691.36593,4151.3413,19364.2784,case rate,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,72572.36,50800.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37257.27471,,,37257.27471,7771.48,84906.16,case rate,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,49815.27,34870.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20640.12897,,,20640.12897,7771.48,46775.3912,case rate,
Other Kidney And Urinary Tract Procedures Without Cc/McC,675,MS-DRG,,,,,,,inpatient,,,67065.03,46945.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14076.12674,,,14076.12674,7771.48,53652.024,case rate,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25198.22,17638.754,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13516.09748,,,13516.09748,7771.48,30436.528,case rate,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,16815.75,11771.025,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8101.303557,,,8101.303557,5608.052625,18012.6696,case rate,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,11199.54,7839.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5614.73832,,,5614.73832,3735.04659,12310.38,case rate,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,17030.3,11921.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16906.30614,,,16906.30614,5679.60505,38209.7984,case rate,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,10555.37,7388.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9548.193027,,,9548.193027,3520.215895,21329.8864,case rate,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,21612.22,15128.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10586.98547,,,10586.98547,7207.67537,23716.9856,case rate,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,14540.91,10178.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7338.992438,,,7338.992438,4849.393485,16263.8864,case rate,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,27273.94,19091.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13237.84951,,,13237.84951,7771.48,29794.1592,case rate,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,11406.89,7984.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7151.727134,,,7151.727134,3804.197815,15834.2896,case rate,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,22314.56,15620.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10211.57153,,,10211.57153,7441.90576,22851.7128,case rate,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,14767.92,10337.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6360.266228,,,6360.266228,4925.10132,14016.6088,case rate,
Urethral Stricture,697,MS-DRG,,,,,,,inpatient,,,14675.76,10273.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9098.579633,,,9098.579633,4894.36596,20300.4752,case rate,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,24798.67,17359.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15097.25264,,,15097.25264,7771.48,34061.7576,case rate,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,17120.52,11984.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9258.461802,,,9258.461802,5709.69342,20665.2272,case rate,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,41107.29,28775.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6381.466073,,,6381.466073,5388.92,32885.832,case rate,
Major Male Pelvic Procedures With Cc/McC,707,MS-DRG,,,,,,,inpatient,,,35017.36,24512.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17391.25262,,,17391.25262,7771.48,39322.292,case rate,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,31613.04,22129.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13344.73206,,,13344.73206,7771.48,30039.3536,case rate,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,20964.14,14674.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20098.64958,,,20098.64958,6991.54069,45533.208,case rate,
Penis Procedures Without Cc/McC,710,MS-DRG,,,,,,,inpatient,,,68393.44,47875.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13511.68085,,,13511.68085,7771.48,54714.752,case rate,
Testes Procedures With Cc/McC,711,MS-DRG,,,,,,,inpatient,,,36907.35,25835.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17126.25454,,,17126.25454,7771.48,38716.3984,case rate,
Testes Procedures Without Cc/McC,712,MS-DRG,,,,,,,inpatient,,,18463.04,12924.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9697.475274,,,9697.475274,6157.42384,21674.3744,case rate,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,14941.94,10459.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13022.31774,,,13022.31774,4983.13699,29299.7176,case rate,
Transurethral Prostatectomy Without Cc/McC,714,MS-DRG,,,,,,,inpatient,,,10164.77,7115.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8550.033625,,,8550.033625,3389.950795,19040.0544,case rate,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC,715,MS-DRG,,,,,,,inpatient,,,36701.12,25690.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20197.58219,,,20197.58219,7771.48,45760.1648,case rate,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,23580.89,16506.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16639.54142,,,16639.54142,7771.48,37597.8256,case rate,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC,718,MS-DRG,,,,,,,inpatient,,,27747.61,19423.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11131.11484,,,11131.11484,7771.48,24961.1952,case rate,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,48176.72,33723.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10168.28851,,,10168.28851,7771.48,38541.376,case rate,
Benign Prostatic Hypertrophy With McC,725,MS-DRG,,,,,,,inpatient,,,31783.16,22248.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11402.2962,,,11402.2962,7771.48,25595.4584,case rate,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,10731.22,7511.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6824.89618,,,6824.89618,3578.86187,15082.4952,case rate,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,9268.85,6488.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7467.074839,,,7467.074839,3091.161475,16557.7144,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC,739,MS-DRG,,,,,,,inpatient,,,70791.15,49553.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35413.77145,,,35413.77145,7771.48,80664.9048,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,inpatient,,,61565.64,43095.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16310.94381,,,16310.94381,7771.48,49252.512,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC,741,MS-DRG,,,,,,,inpatient,,,66917.01,46841.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12382.78906,,,12382.78906,7771.48,53533.608,case rate,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,24878.38,17414.866,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16385.14327,,,16385.14327,7771.48,37014.2224,case rate,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,27909.66,19536.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10837.85031,,,10837.85031,7771.48,24288.4304,case rate,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,16030.6,11221.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8686.949295,,,8686.949295,5346.2051,19354.1464,case rate,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,22664.36,15865.052,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10055.22267,,,10055.22267,7558.56406,22495.0664,case rate,
Infections- Female Reproductive System With McC,757,MS-DRG,,,,,,,inpatient,,,15549.35,10884.545,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12751.13638,,,12751.13638,5185.708225,28677.6128,case rate,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,10151.59,7106.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9253.161841,,,9253.161841,3385.555265,20655.0952,case rate,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,10881.96,7617.372,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8955.480674,,,8955.480674,3629.13366,19970.172,case rate,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14849.95,10394.965,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9933.323558,,,9933.323558,4952.458325,13906.65298,case rate,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,25190.93,17633.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12523.23804,,,12523.23804,7771.48,28156.828,case rate,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,6415.51,4490.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9754.008196,,,9754.008196,2139.572585,21802.0376,case rate,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,10227.7,7159.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6551.948166,,,6551.948166,3410.93795,14456.3376,case rate,
Abortion Without D&C,779,MS-DRG,,,,,,,inpatient,,,13854.84,9698.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8506.750606,,,8506.750606,4620.58914,18940.7608,case rate,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,19969.28,13978.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16521.17561,,,16521.17561,6659.75488,23129.64586,case rate,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,17660.24,12362.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9815.841079,,,9815.841079,5889.69004,14128.192,case rate,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,16297.53,11408.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7965.271214,,,7965.271214,5435.226255,13038.024,case rate,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,19789.47,13852.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14523.09016,,,14523.09016,6599.788245,20332.32622,case rate,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,17268.46,12087.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9628.575776,,,9628.575776,5759.03141,13814.768,case rate,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,16414.17,11489.919,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8240.869208,,,8240.869208,5474.125695,13131.336,case rate,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,4752.37,3326.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16172.26149,,,16172.26149,1584.915395,22641.16608,case rate,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,54759.69,38331.783,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,52761.42854,,,52761.42854,2909,73865.99995,case rate,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39693.75,27785.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36111.59971,,,36111.59971,2909,50556.23959,case rate,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,7967.7,5577.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21888.26989,,,21888.26989,2657.22795,30643.57784,case rate,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,10068.5,7047.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37088.55927,,,37088.55927,2909,51923.98297,case rate,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5320.51,3724.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13289.08247,,,13289.08247,1774.390085,18604.71546,case rate,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4248.78,2974.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2014.297856,,,2014.297856,1378.34,7947.23,case rate,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,9202.02,6441.414,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8801.781793,,,8801.781793,3068.87367,12322.49451,case rate,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,inpatient,,,55562.6,38893.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25987.79005,,,25987.79005,7771.48,59041.1904,case rate,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,36233.96,25363.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10015.47296,,,10015.47296,7771.48,28987.168,case rate,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,14129.33,9890.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9065.01321,,,9065.01321,4712.131555,12691.01849,case rate,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13166.38,9216.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6641.164183,,,6641.164183,4390.98773,10533.104,case rate,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,12520.32,8764.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5878.853065,,,5878.853065,4175.52672,10016.256,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,50163.84,35114.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20480.2468,,,20480.2468,7771.48,46412.6656,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,18648.29,13053.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11189.41442,,,11189.41442,6219.204715,25096.964,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,10877.8,7614.46,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8656.91618,,,8656.91618,3627.7463,19285.2488,case rate,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,32327.52,22629.264,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12676.93692,,,12676.93692,7771.48,28507.3952,case rate,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,22300.24,15610.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8401.634705,,,8401.634705,6364.97,18701.6456,case rate,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,33797.91,23658.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13923.31119,,,13923.31119,7771.48,31366.6456,case rate,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,19042.28,13329.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18715.35965,,,18715.35965,6350.60038,42357.8392,case rate,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,19035.73,13325.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9224.89538,,,9224.89538,6348.415955,20590.2504,case rate,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,34218.62,23953.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22642.63106,,,22642.63106,7771.48,51371.2664,case rate,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,53653,37557.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19968.80052,,,19968.80052,7771.48,45233.3008,case rate,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,70337.4,49236.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41584.69321,,,41584.69321,7771.48,94819.3088,case rate,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,inpatient,,,93776.03,65643.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19677.30265,,,19677.30265,7771.48,75020.824,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,73575.27,51502.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,42432.68704,,,42432.68704,7771.48,96764.6528,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,inpatient,,,54189.56,37932.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21095.04233,,,21095.04233,7771.48,47816.9608,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,45890.81,32123.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14408.25766,,,14408.25766,7771.48,36712.648,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,19580.15,13706.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27489.44579,,,27489.44579,6529.980025,62486.0704,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC,830,MS-DRG,,,,,,,inpatient,,,39587.15,27711.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13168.06668,,,13168.06668,7771.48,31669.72,case rate,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,19450.76,13615.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10416.50337,,,10416.50337,6486.82846,23321.8376,case rate,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,17150.01,12005.007,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6851.395987,,,6851.395987,5642.16,15143.2872,case rate,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,11361.65,7953.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4840.943951,,,4840.943951,3789.110275,10533.2272,case rate,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,9828.38,6879.866,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,49073.53871,,,49073.53871,3277.76473,111997.1016,case rate,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,18619.01,13033.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19116.39006,,,19116.39006,6209.439835,43279.8512,case rate,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,24808.35,17365.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28418.7057,,,28418.7057,7771.48,64630.0016,case rate,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,16962.7,11873.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14099.97657,,,14099.97657,5657.06045,31771.9256,case rate,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,31741.3,22218.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9541.126412,,,9541.126412,7771.48,25393.04,case rate,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,19222.18,13455.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16973.43899,,,16973.43899,6410.59703,38361.7784,case rate,
Radiotherapy,849,MS-DRG,,,,,,,inpatient,,,58144.26,40700.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23843.95566,,,23843.95566,7771.48,54123.1176,case rate,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,85769.92,60038.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,44427.23919,,,44427.23919,7771.48,101350.396,case rate,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,33994.9,23796.43,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17899.16559,,,17899.16559,7771.48,40491.5248,case rate,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65980.01,46186.007,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,40101.58734,,,40101.58734,7771.48,91416.9832,case rate,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,32658.71,22861.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19496.22063,,,19496.22063,7771.48,44153.2296,case rate,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,20565.93,14396.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16491.1425,,,16491.1425,6858.737655,37257.3904,case rate,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,17400.21,12180.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9081.796422,,,9081.796422,5802.970035,20261.9736,case rate,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,17612.23,12328.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8181.686305,,,8181.686305,5873.678705,18195.0456,case rate,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,43267.27,30287.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13286.43249,,,13286.43249,7771.48,34613.816,case rate,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,18403.74,12882.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8065.087154,,,8065.087154,6057.47,17927.5608,case rate,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,61414.22,42989.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19190.58952,,,19190.58952,7771.48,49131.376,case rate,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,15482.04,10837.428,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9525.226528,,,9525.226528,5163.26034,21277.2,case rate,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,13610,9527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6605.831107,,,6605.831107,4538.935,14579.948,case rate,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,148503.39,103952.373,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,61698.04684,,,61698.04684,7771.48,140966.516,case rate,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,33194.92,23236.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17581.1679,,,17581.1679,7771.48,39764.0472,case rate,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,18792.68,13154.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9356.511089,,,9356.511089,6267.35878,20892.184,case rate,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,12279.31,8595.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8716.98241,,,8716.98241,4095.149885,19425.0704,case rate,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,25117.86,17582.502,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15002.73666,,,15002.73666,7771.48,33842.9064,case rate,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,22405.38,15683.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12700.78675,,,12700.78675,7472.19423,28562.108,case rate,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,13917.07,9741.949,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5762.253913,,,5762.253913,3961.38,12646.7624,case rate,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,48007.28,33605.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15979.69622,,,15979.69622,7771.48,38405.824,case rate,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,20565.28,14395.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8042.120655,,,8042.120655,5972.81,17876.9008,case rate,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,61408.52,42985.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35438.50461,,,35438.50461,7771.48,80721.644,case rate,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,26863.69,18804.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18066.9977,,,18066.9977,7771.48,40872.488,case rate,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,27835,19484.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11452.64583,,,11452.64583,7771.48,25698.8048,case rate,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,30162.14,21113.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14544.29,,,14544.29,7771.48,32791.2048,case rate,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42212,29548.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15600.74898,,,15600.74898,7771.48,35214.7792,case rate,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,17347.78,12143.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6115.584675,,,6115.584675,4755.82,13878.224,case rate,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,43962.28,30773.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14733.32196,,,14733.32196,7771.48,35169.824,case rate,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,17818.34,12472.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8063.3205,,,8063.3205,5723.92,17921.4816,case rate,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,31482.85,22037.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16357.76014,,,16357.76014,7771.48,36949.3776,case rate,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,15673.65,10971.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9223.128726,,,9223.128726,5227.162275,20584.1712,case rate,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,7247.46,5073.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6324.049825,,,6324.049825,2417.02791,13933.5264,case rate,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,28001.68,19601.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9258.461802,,,9258.461802,6731.81,22401.344,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC,939,MS-DRG,,,,,,,inpatient,,,23950.54,16765.378,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28286.20666,,,28286.20666,7771.48,64313.8832,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,49540.17,34678.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18899.97497,,,18899.97497,7771.48,42783.3832,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC,941,MS-DRG,,,,,,,inpatient,,,17064.75,11945.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17512.2684,,,17512.2684,5691.094125,39599.9088,case rate,
Rehabilitation With Cc/McC,945,MS-DRG,,,,,,,inpatient,,,45131.85,31592.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13733.3959,,,13733.3959,7771.48,36105.48,case rate,
Rehabilitation Without Cc/McC,946,MS-DRG,,,,,,,inpatient,,,44615.43,31230.801,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10111.75559,,,10111.75559,7771.48,35692.344,case rate,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,22069.35,15448.545,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11610.76135,,,11610.76135,7360.128225,26061.5304,case rate,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,17906.41,12534.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7267.442959,,,7267.442959,5684.12,16099.748,case rate,
Aftercare With Cc/McC,949,MS-DRG,,,,,,,inpatient,,,33492.73,23444.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9780.508003,,,9780.508003,7771.48,26794.184,case rate,
Aftercare Without Cc/McC,950,MS-DRG,,,,,,,inpatient,,,9898.64,6929.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5426.589689,,,5426.589689,3301.19644,11876.7304,case rate,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,4337.06,3035.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5257.87425,,,5257.87425,1446.40951,11487.6616,case rate,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,61892.75,43324.925,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34013.69831,,,34013.69831,7771.48,77453.0608,case rate,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,12905.91,9034.137,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13500.1976,,,13500.1976,4304.120985,30400.0528,case rate,
Other Multiple Significant Trauma Without Cc/McC,965,MS-DRG,,,,,,,inpatient,,,19234.18,13463.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8310.652034,,,8310.652034,6414.59903,18490.9,case rate,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,37958.81,26571.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26627.31873,,,26627.31873,7771.48,60508.304,case rate,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,12545.67,8781.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12986.10134,,,12986.10134,4183.980945,29216.6352,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,108861.48,76203.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,42241.88843,,,42241.88843,7771.48,96341.1352,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,62893.24,31446.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21875.9,,,21875.9,7771.48,50314.592,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,59507.83,29753.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14985.07,,,14985.07,7771.48,47606.264,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51559.92,25779.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31189.7,,,31189.7,7771.48,70984.792,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,16279.53,8139.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15407.3,,,15407.3,5429.223255,34773.024,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,989,MS-DRG,,,,,,,inpatient,,,64497.43,32248.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10456.25,,,10456.25,7771.48,51597.944,case rate,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,17.7355,1592,other,OPPS APC
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,399.86,2141,other,OPPS APC
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,57.921,1592,other,OPPS APC
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,195.5395,1592,other,OPPS APC
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,155.354,2141,other,OPPS APC
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,291.227805,2141,other,OPPS APC
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,29.185,1592,other,OPPS APC
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,206.989,1592,other,OPPS APC
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,206.989,1592,other,OPPS APC
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3715.584,other,OPPS APC
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,205.642,1592,other,OPPS APC
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,205.642,1592,other,OPPS APC
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6635.52,other,OPPS APC
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,263.563,1592,other,OPPS APC
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.8985,1592,other,OPPS APC
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,158.497,3914,fee schedule,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,399.86,2141,other,OPPS APC
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,399.86,2141,other,OPPS APC
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,228.541,1592,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,239.0925,1592,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.0735,1592,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.0735,1592,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1592,other,OPPS APC
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,62.19,1592,other,OPPS APC
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,66.75974,1592,other,OPPS APC
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,47.594,1592,other,OPPS APC
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,96.7595,1592,other,OPPS APC
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.2055,1592,other,OPPS APC
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,35.6955,1592,other,OPPS APC
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,399.86,1592,other,OPPS APC
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,399.86,2141,other,OPPS APC
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,113.876282,1592,other,OPPS APC
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,156.65,1592,other,OPPS APC
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,113.3725,1592,other,OPPS APC
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,113.3725,1592,other,OPPS APC
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,99.9025,1592,other,OPPS APC
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,115.1685,1592,other,OPPS APC
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,145.476,1592,other,OPPS APC
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,95.4125,1592,other,OPPS APC
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,73.8605,1592,other,OPPS APC
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,89.8,1592,other,OPPS APC
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,107.5355,1592,other,OPPS APC
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,142.1085,1592,other,OPPS APC
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,174.8855,1592,other,OPPS APC
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,124.5975,1592,other,OPPS APC
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,100.576,1592,other,OPPS APC
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,309.1365,1592,other,OPPS APC
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,181.6205,1592,other,OPPS APC
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,200.0295,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,113.3725,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,153.7825,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,153.7825,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,145.7005,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,142.333,1592,other,OPPS APC
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,142.1085,1592,other,OPPS APC
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,139.8635,1592,other,OPPS APC
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,140.7615,1592,other,OPPS APC
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,237.072,2141,other,OPPS APC
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,4022.784,other,OPPS APC
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,200.0295,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,133.802,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,148.8435,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,146.374,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,168.1505,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,318.5655,1592,other,OPPS APC
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,254.134,1592,other,OPPS APC
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,399.86,1592,other,OPPS APC
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,244.705,1592,other,OPPS APC
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,56.125,1592,other,OPPS APC
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,395.3445,1592,other,OPPS APC
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,165.0075,1592,other,OPPS APC
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,68.4725,1592,other,OPPS APC
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,257.0525,1592,other,OPPS APC
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,162.3135,1592,other,OPPS APC
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.761,1592,other,OPPS APC
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,395.3445,1592,other,OPPS APC
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,166.8035,1592,other,OPPS APC
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,103.719,1592,other,OPPS APC
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,108.7,1592,other,OPPS APC
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,5804.544,other,OPPS APC
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3915.61683,,,3915.61683,399.86,7323.648,other,OPPS APC
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,4478.208,other,OPPS APC
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,5804.544,other,OPPS APC
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3915.61683,,,3915.61683,399.86,5481.863562,other,OPPS APC
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,7323.648,other,OPPS APC
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,5804.544,other,OPPS APC
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,88.2285,1592,other,OPPS APC
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,182.294,1592,other,OPPS APC
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,182.294,1592,other,OPPS APC
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,189.7025,1592,other,OPPS APC
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.415,2998,fee schedule,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,395.7935,1592,other,OPPS APC
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.47,1592,other,OPPS APC
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3315.456,other,OPPS APC
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3070.464,other,OPPS APC
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1794.048,other,OPPS APC
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3932.16,other,OPPS APC
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1714.176,other,OPPS APC
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,108.7,2998,other,OPPS APC
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,197.56,1592,other,OPPS APC
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,108.7,2141,other,OPPS APC
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.858,1592,other,OPPS APC
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,108.7,2141,other,OPPS APC
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,61.513,1592,other,OPPS APC
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,108.7,2141,other,OPPS APC
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10288.44571,,,10288.44571,399.86,14403.82399,other,OPPS APC
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2954.496,other,OPPS APC
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4449.024,other,OPPS APC
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,184.7635,1592,other,OPPS APC
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,202.7235,1592,other,OPPS APC
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,147.721,1592,other,OPPS APC
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,160.293,1592,other,OPPS APC
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,160.293,1592,other,OPPS APC
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,210.581,1592,other,OPPS APC
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,169.0485,1592,other,OPPS APC
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,169.0485,1592,other,OPPS APC
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,399.86,2141,other,OPPS APC
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,147.721,1592,other,OPPS APC
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,147.721,1592,other,OPPS APC
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,176.008,1592,other,OPPS APC
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14364.36381,,,14364.36381,399.86,20110.10933,other,OPPS APC
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3683.328,other,OPPS APC
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,380.5275,1592,other,OPPS APC
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.382395,,,257.382395,165.0075,1592,other,OPPS APC
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,2998,other,OPPS APC
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,274.788,1592,other,OPPS APC
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7808.106015,,,7808.106015,399.86,16604.928,other,OPPS APC
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,2455.793921,other,OPPS APC
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2841.6,other,OPPS APC
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2841.6,other,OPPS APC
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.382395,,,257.382395,202.499,1592,other,OPPS APC
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,2455.793921,other,OPPS APC
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.382395,,,257.382395,150.6395,1592,other,OPPS APC
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,2998,other,OPPS APC
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.382395,,,257.382395,160.5175,1592,other,OPPS APC
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,5885.184,other,OPPS APC
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,324.627,1592,other,OPPS APC
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,187.233,1592,other,OPPS APC
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,292.65,2813.184,other,OPPS APC
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,293.11054,,,293.11054,149.068,1592,other,OPPS APC
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,293.11054,,,293.11054,200.4785,1592,other,OPPS APC
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,110.2295,1592,other,OPPS APC
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,114.7195,1592,other,OPPS APC
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,101.6985,1592,other,OPPS APC
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,79.473,1592,other,OPPS APC
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,79.473,1592,other,OPPS APC
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,49.6145,1592,other,OPPS APC
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,48.941,1592,other,OPPS APC
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,90.9225,1592,other,OPPS APC
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,27.389,1592,other,OPPS APC
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,27.389,1592,other,OPPS APC
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,293.11054,,,293.11054,156.9255,1592,other,OPPS APC
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,124.373,1592,other,OPPS APC
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,79.473,1592,other,OPPS APC
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,77.9015,1592,other,OPPS APC
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,77.9015,1592,other,OPPS APC
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,64.8805,1592,other,OPPS APC
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,64.8805,1592,other,OPPS APC
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,109.107,1592,other,OPPS APC
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,114.495,1592,other,OPPS APC
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,122.128,1592,other,OPPS APC
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,122.128,1592,other,OPPS APC
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,122.128,1592,other,OPPS APC
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,138.0675,1592,other,OPPS APC
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,216.190215,,,216.190215,83.2895,1592,other,OPPS APC
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1852.43387,,,1852.43387,399.86,3022.08,other,OPPS APC
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3528.192,other,OPPS APC
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,399.86,2141,other,OPPS APC
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1512.300555,,,1512.300555,399.86,3224.064,other,OPPS APC
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,399.86,2141,other,OPPS APC
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,367.282,2141,other,OPPS APC
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,367.282,2141,other,OPPS APC
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2076.780045,,,2076.780045,399.86,2998,other,OPPS APC
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,399.86,1739.52,other,OPPS APC
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4252.416,other,OPPS APC
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4252.416,other,OPPS APC
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,28237.056,other,OPPS APC
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21266.60843,,,21266.60843,399.86,37615.872,other,OPPS APC
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,2998,other,OPPS APC
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6364,other,OPPS APC
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,13659.648,other,OPPS APC
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,16316.30039,other,OPPS APC
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21266.60843,,,21266.60843,399.86,29773.2518,other,OPPS APC
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25726.38358,,,25726.38358,399.86,51836.928,other,OPPS APC
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35906.82009,,,35906.82009,399.86,50269.54813,other,OPPS APC
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6933.504,other,OPPS APC
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35906.82009,,,35906.82009,399.86,66342.912,other,OPPS APC
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25726.38358,,,25726.38358,399.86,48388.608,other,OPPS APC
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25726.38358,,,25726.38358,399.86,50497.536,other,OPPS APC
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35906.82009,,,35906.82009,399.86,50497.536,other,OPPS APC
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21295.104,fee schedule,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24913.5068,fee schedule,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21295.104,fee schedule,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,22573.824,fee schedule,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,22573.824,fee schedule,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24913.5068,fee schedule,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23502.2528,fee schedule,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24913.5068,fee schedule,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24913.5068,fee schedule,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5338.368,fee schedule,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4584.96,fee schedule,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3746.392,fee schedule,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,370.2005,2998,fee schedule,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3237.832,fee schedule,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3220.992,fee schedule,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6913,fee schedule,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.2055,6913,fee schedule,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3155.712,fee schedule,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3549.7488,fee schedule,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3549.7488,fee schedule,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3155.712,fee schedule,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,293.5896,3216.384,fee schedule,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,397.365,2141,other,OPPS APC
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,397.365,2141,other,OPPS APC
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.124,2998,fee schedule,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.431,2998,fee schedule,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,37.4915,2998,fee schedule,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,75.6565,2998,fee schedule,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.3515,2998,fee schedule,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.941,2998,fee schedule,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,77.0035,1592,other,OPPS APC
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,173.9875,2141,other,OPPS APC
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,57.921,1592,other,OPPS APC
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,121.4545,1592,other,OPPS APC
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,173.5385,1592,other,OPPS APC
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,204.0705,1592,other,OPPS APC
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6398.208,other,OPPS APC
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,161.8645,1592,other,OPPS APC
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,373.119,1592,other,OPPS APC
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,140.986,1592,other,OPPS APC
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,76.33,1592,other,OPPS APC
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2003.712,other,OPPS APC
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,161.8645,1592,other,OPPS APC
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.235,1592,other,OPPS APC
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.516,1592,other,OPPS APC
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,346.8525,1592,other,OPPS APC
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.4705,1592,other,OPPS APC
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7442.688,other,OPPS APC
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7442.688,other,OPPS APC
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,8396.844904,other,OPPS APC
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,12170.496,other,OPPS APC
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7020.288,other,OPPS APC
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,12170.496,other,OPPS APC
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,115.6175,1592,other,OPPS APC
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.394,1592,other,OPPS APC
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.5215,1592,other,OPPS APC
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,277.482,1592,other,OPPS APC
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,323.729,1592,other,OPPS APC
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,57.921,1592,other,OPPS APC
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,8396.844904,other,OPPS APC
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.388,416.02,other,OPPS APC
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,473.790255,,,473.790255,207.2135,1592,other,OPPS APC
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,156.65,1592,other,OPPS APC
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,204.0705,1592,other,OPPS APC
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,85.9835,1592,other,OPPS APC
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6623.08,other,OPPS APC
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1592,other,OPPS APC
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1592,other,OPPS APC
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,205.4175,1592,other,OPPS APC
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,92.494,1592,other,OPPS APC
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,173.5385,1592,other,OPPS APC
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,473.790255,,,473.790255,300.1565,2081.64,other,OPPS APC
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1674.594995,,,1674.594995,399.86,3777.792,other,OPPS APC
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2953.728,other,OPPS APC
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2953.728,other,OPPS APC
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2998,other,OPPS APC
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,35.92,1592,other,OPPS APC
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,28.0625,1592,other,OPPS APC
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,180.947,1592,other,OPPS APC
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,91.147,1592,other,OPPS APC
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,66.6765,1592,other,OPPS APC
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,69.3705,1592,other,OPPS APC
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9071.0152,fee schedule,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,127.516,1592,other,OPPS APC
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,127.516,1592,other,OPPS APC
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5756,fee schedule,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,18955.84,other,OPPS APC
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,184.988,4800.911611,other,OPPS APC
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,277.482,8164.18419,other,OPPS APC
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6788.57,other,OPPS APC
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,10775.04,other,OPPS APC
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7394.304,other,OPPS APC
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7678.464,other,OPPS APC
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,137.6185,1592,other,OPPS APC
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6777.6,other,OPPS APC
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5548.032,other,OPPS APC
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5548.032,other,OPPS APC
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,124.1485,2998,fee schedule,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,12283.392,other,OPPS APC
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,18955.84,other,OPPS APC
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12148.224,other,OPPS APC
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12453.888,other,OPPS APC
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,12748.032,other,OPPS APC
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,25020.672,other,OPPS APC
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,45315.84,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,44656.128,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12327.936,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,25786.368,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12327.936,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12148.224,other,OPPS APC
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4532,other,OPPS APC
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4532,other,OPPS APC
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3565.824,other,OPPS APC
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,85.5345,1592,other,OPPS APC
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.25,1592,other,OPPS APC
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,121.23,1592,other,OPPS APC
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,95.188,1592,other,OPPS APC
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,600.505465,,,600.505465,119.6585,1592,other,OPPS APC
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,153.7825,1592,other,OPPS APC
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,72.9625,1592,other,OPPS APC
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,72.9625,1592,other,OPPS APC
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,129.9855,1592,other,OPPS APC
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,111.352,1592,other,OPPS APC
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,375.5885,2998,other,OPPS APC
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1287.95438,,,1287.95438,399.86,4005.9,other,OPPS APC
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3064.48742,,,3064.48742,399.86,4934.4,other,OPPS APC
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1287.95438,,,1287.95438,399.86,2998,other,OPPS APC
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,218.214,1592,other,OPPS APC
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6297.489345,,,6297.489345,399.86,10219.776,other,OPPS APC
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11234.78908,,,11234.78908,399.86,15728.70471,other,OPPS APC
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,390.63,2998,fee schedule,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6577.152,fee schedule,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6577.152,fee schedule,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,207.6625,2998,other,OPPS APC
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,367.0575,2998,other,OPPS APC
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,367.0575,2998,other,OPPS APC
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6116.352,other,OPPS APC
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,110.2295,1592,other,OPPS APC
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,369.078,2998,other,OPPS APC
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,369.078,2998,other,OPPS APC
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,379.854,2998,other,OPPS APC
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,379.854,2998,other,OPPS APC
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,2998,other,OPPS APC
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,2998,other,OPPS APC
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,2998,other,OPPS APC
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,136.047,1592,other,OPPS APC
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,4179.83,other,OPPS APC
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,745.56013,,,745.56013,339.6685,2141,other,OPPS APC
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,162.987,2141,other,OPPS APC
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,119.6585,1592,other,OPPS APC
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,745.56013,,,745.56013,334.48,2141,other,OPPS APC
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,4225.536,other,OPPS APC
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6297.489345,,,6297.489345,399.86,10219.776,other,OPPS APC
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,83.963,1592,other,OPPS APC
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,119.6585,1592,other,OPPS APC
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,156.9255,1592,other,OPPS APC
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,156.9255,1592,other,OPPS APC
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1141.12419,,,1141.12419,179.53,2998,other,OPPS APC
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1141.12419,,,1141.12419,179.53,2998,other,OPPS APC
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,219.112,1592,other,OPPS APC
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,87.3305,1592,other,OPPS APC
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,87.7795,1592,other,OPPS APC
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,79.473,1592,other,OPPS APC
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,102.372,1592,other,OPPS APC
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,106.6375,1592,other,OPPS APC
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,47.594,1592,other,OPPS APC
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3804.86989,,,3804.86989,399.86,6210.048,other,OPPS APC
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,5068.032,other,OPPS APC
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,120.28264,1592,other,OPPS APC
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,350.13353,,,350.13353,186.1105,1592,other,OPPS APC
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3412.181035,,,3412.181035,399.86,4777.053449,other,OPPS APC
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3412.181035,,,3412.181035,399.86,5299.2,other,OPPS APC
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,217.48463,,,217.48463,110.005,416.02,other,OPPS APC
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3412.181035,,,3412.181035,399.86,4777.053449,other,OPPS APC
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3412.181035,,,3412.181035,399.86,5511.168,other,OPPS APC
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,339.893,2141,other,OPPS APC
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6297.489345,,,6297.489345,399.86,11413.04,other,OPPS APC
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,399.86,2141,other,OPPS APC
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,119.6585,5756,fee schedule,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,281.972,2141,other,OPPS APC
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,281.972,2141,other,OPPS APC
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,294.544,1592,other,OPPS APC
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2107.296165,,,2107.296165,399.86,6224.0876,other,OPPS APC
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,281.972,1592,other,OPPS APC
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.5215,1592,other,OPPS APC
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,325.997845,,,325.997845,155.844464,1592,other,OPPS APC
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,200.0295,1592,other,OPPS APC
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,323.2601,1592,other,OPPS APC
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,196.8865,1592,other,OPPS APC
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,346.628,2141,other,OPPS APC
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,346.628,2141,other,OPPS APC
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,346.628,2141,other,OPPS APC
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,310.259,2141,other,OPPS APC
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,346.628,2141,other,OPPS APC
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,346.628,2141,other,OPPS APC
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,399.86,2141,other,OPPS APC
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,346.628,2141,other,OPPS APC
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,4677.12,other,OPPS APC
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,366.833,2141,other,OPPS APC
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,185.2125,1592,other,OPPS APC
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.635,1592,other,OPPS APC
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,93.392,1592,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,49.6145,1592,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.288,1592,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,380.0785,1592,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.123,1592,other,OPPS APC
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,154.2315,1592,other,OPPS APC
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,154.2315,1592,other,OPPS APC
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,46.0225,1592,other,OPPS APC
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,66.75974,1592,other,OPPS APC
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,60.8395,416.02,other,OPPS APC
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,456.96,other,OPPS APC
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.208,416.02,other,OPPS APC
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,66.2275,416.02,other,OPPS APC
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,56.574,416.02,other,OPPS APC
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,73.636,416.02,other,OPPS APC
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,549.888,other,OPPS APC
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1987.584,other,OPPS APC
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,120.5565,646.6965,other,OPPS APC
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,89.81,821.76,other,OPPS APC
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,124.33,1023.744,other,OPPS APC
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,153.75,1240.32,other,OPPS APC
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,575,other,OPPS APC
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,173.763,667.43,other,OPPS APC
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1243.392,other,OPPS APC
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,921.6,other,OPPS APC
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1014.528,other,OPPS APC
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,889.344,other,OPPS APC
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,575,other,OPPS APC
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,194.55,1138.176,other,OPPS APC
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1347.84,other,OPPS APC
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1021.44,other,OPPS APC
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,888.576,other,OPPS APC
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,3902.208,other,OPPS APC
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,365.99,2081.28,other,OPPS APC
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,379.854,1299.456,other,OPPS APC
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1750.272,other,OPPS APC
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,374.62,1750.272,other,OPPS APC
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,301.425681,1750.272,other,OPPS APC
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1675.776,other,OPPS APC
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.86,1896.192,other,OPPS APC
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,301.425681,1946.112,other,OPPS APC
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,188.66,1605.12,other,OPPS APC
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,268.7,4035.84,other,OPPS APC
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,307.14,2049.024,other,OPPS APC
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,48.043,416.02,other,OPPS APC
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,55.0025,416.02,other,OPPS APC
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,431.616,other,OPPS APC
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,56.125,416.02,other,OPPS APC
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,1065.984,other,OPPS APC
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,195.34,1247.232,other,OPPS APC
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1522.176,other,OPPS APC
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,59.268,575,other,OPPS APC
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1222.656,other,OPPS APC
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,1519.872,other,OPPS APC
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,399.86,2402.304,other,OPPS APC
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,347.3015,1288.93,other,OPPS APC
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1817.856,other,OPPS APC
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1817.856,other,OPPS APC
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1817.856,other,OPPS APC
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,56.3495,416.02,other,OPPS APC
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,66.452,416.02,other,OPPS APC
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,67.35,416.02,other,OPPS APC
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,67.35,416.02,other,OPPS APC
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,56.574,416.02,other,OPPS APC
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,63.5335,416.02,other,OPPS APC
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,581.376,other,OPPS APC
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,581.376,other,OPPS APC
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,52.7575,416.02,other,OPPS APC
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,72.5135,416.02,other,OPPS APC
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,462.336,other,OPPS APC
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,92.2695,416.02,other,OPPS APC
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,1043.712,other,OPPS APC
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,196.52,1195.008,other,OPPS APC
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1719.552,other,OPPS APC
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,698.112,other,OPPS APC
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,196.52,796.416,other,OPPS APC
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1704.192,other,OPPS APC
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,575,other,OPPS APC
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,195.73,1095.936,other,OPPS APC
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1057.536,other,OPPS APC
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,185.92,1624.32,other,OPPS APC
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,270.27,2337.024,other,OPPS APC
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,185.92,1706.496,other,OPPS APC
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,266.73,2183.424,other,OPPS APC
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,185.92,2035.968,other,OPPS APC
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,265.17,2031.36,other,OPPS APC
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,307.53,2399.232,other,OPPS APC
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,307.93,2175.744,other,OPPS APC
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,305.58,2443.008,other,OPPS APC
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,64.4315,416.02,other,OPPS APC
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,974.592,other,OPPS APC
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,1050.624,other,OPPS APC
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,195.33,1198.848,other,OPPS APC
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1460.736,other,OPPS APC
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,1721.088,other,OPPS APC
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,372.27,2188.8,other,OPPS APC
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2114.304,other,OPPS APC
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2233.344,other,OPPS APC
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2233.344,other,OPPS APC
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2233.344,other,OPPS APC
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,331.811,2051.3855,other,OPPS APC
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,399.86,2051.3855,other,OPPS APC
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,395.12,2051.3855,other,OPPS APC
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,399.86,2051.3855,other,OPPS APC
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2107.296165,,,2107.296165,399.86,4977.9345,other,OPPS APC
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2107.296165,,,2107.296165,399.86,4977.9345,other,OPPS APC
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,38.165,416.02,other,OPPS APC
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,57.472,416.02,other,OPPS APC
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,31.2055,416.02,other,OPPS APC
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,379.405,1297.92,other,OPPS APC
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,39.961,416.02,other,OPPS APC
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,38.3895,416.02,other,OPPS APC
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,28.9605,416.02,other,OPPS APC
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,298.8095,1022.208,other,OPPS APC
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,50.5125,416.02,other,OPPS APC
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,42.655,416.02,other,OPPS APC
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1322.496,other,OPPS APC
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.982,416.02,other,OPPS APC
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,28.9605,416.02,other,OPPS APC
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,736.512,other,OPPS APC
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,193.37,1065.984,other,OPPS APC
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1506.048,other,OPPS APC
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1032.96,other,OPPS APC
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,2217.984,other,OPPS APC
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,371.09,2254.848,other,OPPS APC
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2414.592,other,OPPS APC
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,204.76,2333.952,other,OPPS APC
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,340.49,2414.592,other,OPPS APC
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2350.08,other,OPPS APC
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,49.839,416.02,other,OPPS APC
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,49.839,416.02,other,OPPS APC
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,581.376,other,OPPS APC
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1241.088,other,OPPS APC
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,47.8185,416.02,other,OPPS APC
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,47.8185,416.02,other,OPPS APC
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,58.37,416.02,other,OPPS APC
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,382.548,1308.672,other,OPPS APC
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,44.6755,416.02,other,OPPS APC
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,51.8595,416.02,other,OPPS APC
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,30.7565,416.02,other,OPPS APC
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,29.185,416.02,other,OPPS APC
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,35.471,416.02,other,OPPS APC
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,36.818,416.02,other,OPPS APC
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.533,416.02,other,OPPS APC
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,43.104,416.02,other,OPPS APC
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,743.424,other,OPPS APC
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,196.51,758.016,other,OPPS APC
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1461.504,other,OPPS APC
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,903.168,other,OPPS APC
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,2178.048,other,OPPS APC
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,372.66,1840.128,other,OPPS APC
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2350.08,other,OPPS APC
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,205.15,2310.144,other,OPPS APC
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,345.98,2317.824,other,OPPS APC
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2379.264,other,OPPS APC
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2290.176,other,OPPS APC
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2290.176,other,OPPS APC
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2290.176,other,OPPS APC
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,92.045,416.02,other,OPPS APC
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,1112.832,other,OPPS APC
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,194.55,1218.048,other,OPPS APC
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1580.544,other,OPPS APC
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,329.339098,1982.208,other,OPPS APC
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1040.64,other,OPPS APC
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,142.38,1050.624,other,OPPS APC
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,204.61123,1513.728,other,OPPS APC
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,204.61123,1629.696,other,OPPS APC
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,1810.176,other,OPPS APC
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,3902.208,other,OPPS APC
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2072.064,other,OPPS APC
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1878.528,other,OPPS APC
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1878.528,other,OPPS APC
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1878.528,other,OPPS APC
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,76.026473,753.408,other,OPPS APC
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,128.66,671.232,other,OPPS APC
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,259.7465,888.576,other,OPPS APC
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,703.488,other,OPPS APC
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,194.1925,664.32,other,OPPS APC
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,128.66,2264.832,other,OPPS APC
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,183.14,907.776,other,OPPS APC
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,822.528,other,OPPS APC
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1350.144,other,OPPS APC
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,1026.048,other,OPPS APC
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,64.8805,416.02,other,OPPS APC
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,797.184,other,OPPS APC
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.08,669.696,other,OPPS APC
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,260.23,2237.184,other,OPPS APC
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,141.6595,484.608,other,OPPS APC
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1890.816,other,OPPS APC
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,134.4755,499.422,other,OPPS APC
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1595.904,other,OPPS APC
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.86,2172.672,other,OPPS APC
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,171.069,646.6965,other,OPPS APC
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,171.069,646.6965,other,OPPS APC
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,121.679,1393.3385,other,OPPS APC
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,5136.771,other,OPPS APC
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.819698,1301.76,other,OPPS APC
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,285.115,975.36,other,OPPS APC
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,88.902,1706.496,other,OPPS APC
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,88.902,1706.496,other,OPPS APC
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,102.5965,2030.592,other,OPPS APC
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,102.5965,2030.592,other,OPPS APC
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.2045,836,other,OPPS APC
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.2045,836,other,OPPS APC
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,19.0825,575,other,OPPS APC
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,19.0825,575,other,OPPS APC
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,58.819,669.696,other,OPPS APC
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,58.819,669.696,other,OPPS APC
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,58.819,780.288,other,OPPS APC
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,58.819,780.288,other,OPPS APC
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,57.921,824.064,other,OPPS APC
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,57.921,824.064,other,OPPS APC
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1141.12419,,,1141.12419,399.86,2536.61118,other,OPPS APC
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1321.728,other,OPPS APC
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2717.184,other,OPPS APC
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,92.2695,416.02,other,OPPS APC
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,399.86,3400.704,other,OPPS APC
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,367.731,1602.0655,other,OPPS APC
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,1947.648,other,OPPS APC
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,260.23,8249.769,other,OPPS APC
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,260.23,3665.664,other,OPPS APC
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,105.7395,416.02,other,OPPS APC
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,324.627,1110.528,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,294.544,1007.616,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,189.7025,648.96,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,167.028,571.392,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,2241.024,other,OPPS APC
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,2215.68,other,OPPS APC
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,681.984,other,OPPS APC
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,681.984,other,OPPS APC
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,195.08,765.696,other,OPPS APC
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,237.819698,1497.6,other,OPPS APC
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,220.908,1393.3385,other,OPPS APC
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,85.759,416.02,other,OPPS APC
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.024,836,other,OPPS APC
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.024,836,other,OPPS APC
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.024,836,other,OPPS APC
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,94.739,836,other,OPPS APC
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,94.739,836,other,OPPS APC
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,94.739,836,other,OPPS APC
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,712.704,other,OPPS APC
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,81.08,1703.424,other,OPPS APC
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,189.029,836,other,OPPS APC
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,51.4105,575,other,OPPS APC
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,97.2085,416.02,other,OPPS APC
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,99.678,416.02,other,OPPS APC
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,93.6165,416.02,other,OPPS APC
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,103.4945,416.02,other,OPPS APC
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.5545,416.02,other,OPPS APC
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,58.5945,416.02,other,OPPS APC
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,82.616,416.02,other,OPPS APC
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,77.4525,416.02,other,OPPS APC
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,456.96,other,OPPS APC
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,64.8805,416.02,other,OPPS APC
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.288,416.02,other,OPPS APC
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,94.5145,416.02,other,OPPS APC
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.086513,547.584,other,OPPS APC
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,162.7625,646.6965,other,OPPS APC
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,68.0235,416.02,other,OPPS APC
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,460.8,other,OPPS APC
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,79.6975,416.02,other,OPPS APC
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,98.5555,416.02,other,OPPS APC
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,80.371,416.02,other,OPPS APC
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,65.105,416.02,other,OPPS APC
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,443.904,other,OPPS APC
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,32.777,416.02,other,OPPS APC
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,81.9425,416.02,other,OPPS APC
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,199.512292,772.608,other,OPPS APC
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,81.0445,416.02,other,OPPS APC
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,74.534,416.02,other,OPPS APC
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,102.5965,416.02,other,OPPS APC
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,90.0245,416.02,other,OPPS APC
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,61.2885,416.02,other,OPPS APC
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,89.8,416.02,other,OPPS APC
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,56.7985,416.02,other,OPPS APC
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,152.8845,775.5705,other,OPPS APC
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,56.3495,416.02,other,OPPS APC
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,103.27,416.02,other,OPPS APC
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,166.37,666.624,other,OPPS APC
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.473,416.02,other,OPPS APC
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,135.598,463.872,other,OPPS APC
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,116.9645,416.02,other,OPPS APC
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,71.391,416.02,other,OPPS APC
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,116.291,416.02,other,OPPS APC
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1383.168,other,OPPS APC
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.344499,1341.696,other,OPPS APC
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.344499,1347.84,other,OPPS APC
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,139.8635,575,other,OPPS APC
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2374.656,other,OPPS APC
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,189.029,836,other,OPPS APC
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,189.029,836,other,OPPS APC
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.547552,1936.896,other,OPPS APC
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.547552,1936.896,other,OPPS APC
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.547552,2548.224,other,OPPS APC
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.547552,2548.224,other,OPPS APC
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,72.0645,416.02,fee schedule,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,88.2285,416.02,fee schedule,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25.43,,,25.43,22.99364,416.02,fee schedule,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,92.45,,,92.45,88.2285,416.02,fee schedule,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,118.49,,,118.49,90.800319,416.02,fee schedule,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,97.74,,,97.74,90.800319,416.02,fee schedule,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,48.941,416.02,other,OPPS APC
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,112.699,416.02,other,OPPS APC
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,112.699,416.02,other,OPPS APC
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,441.6,other,OPPS APC
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,25.593,416.02,other,OPPS APC
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1847.808,other,OPPS APC
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,55.676,416.02,other,OPPS APC
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,55.676,416.02,other,OPPS APC
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,209.9075,1076.394,other,OPPS APC
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,142.1085,1076.394,other,OPPS APC
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,220.459,1076.394,other,OPPS APC
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,235.5005,1397.122,other,OPPS APC
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,38.3895,416.02,other,OPPS APC
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,353.5875,1209.6,other,OPPS APC
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,304.6465,1076.394,other,OPPS APC
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,358.69,1457.664,other,OPPS APC
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,314.9735,1077.504,other,OPPS APC
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,314.9735,1077.504,other,OPPS APC
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,147.9455,1076.394,other,OPPS APC
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,217.9895,1076.394,other,OPPS APC
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,240.4395,1397.122,other,OPPS APC
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,399.86,2239.93036,other,OPPS APC
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,270.5225,1076.394,other,OPPS APC
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,310.708,1076.394,other,OPPS APC
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,310.708,1397.122,other,OPPS APC
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,176.906,1076.394,other,OPPS APC
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,234.1535,1076.394,other,OPPS APC
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,188.131,1076.394,other,OPPS APC
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,399.86,1596.672,other,OPPS APC
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,200.4785,1076.394,other,OPPS APC
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,214.173,1076.394,other,OPPS APC
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,215.969,1076.394,other,OPPS APC
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,246.501,1076.394,other,OPPS APC
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,200.4785,1076.394,other,OPPS APC
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,214.622,1076.394,other,OPPS APC
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,356.057,1218.048,other,OPPS APC
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,375.1395,1283.328,other,OPPS APC
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,172.1915,1076.394,other,OPPS APC
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,143.68,1076.394,other,OPPS APC
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,212.377,1397.122,other,OPPS APC
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,202.499,1076.394,other,OPPS APC
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,336.5255,1397.122,other,OPPS APC
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,399.86,2076.672,other,OPPS APC
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,356.7305,1397.122,other,OPPS APC
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,3755.52,other,OPPS APC
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,399.86,1973.76,other,OPPS APC
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,205.642,1397.122,other,OPPS APC
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,290.054,1076.394,other,OPPS APC
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,271.645,1397.122,other,OPPS APC
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,201.8255,1397.122,other,OPPS APC
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,189.7025,1076.394,other,OPPS APC
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,194.6415,1076.394,other,OPPS APC
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,275.4615,1076.394,other,OPPS APC
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,3982.848,other,OPPS APC
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,5302.272,other,OPPS APC
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,5917.44,other,OPPS APC
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,4124.5085,other,OPPS APC
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.5735,416.02,other,OPPS APC
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,271.52932,,,271.52932,175.559,691.5815,other,OPPS APC
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.29,24.576,fee schedule,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.286,21.504,fee schedule,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,185.2,,,185.2,160.742,549.888,fee schedule,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.33,18.432,fee schedule,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.4,34.56,fee schedule,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,938.496695,,,938.496695,39.73,1313.895373,other,OPPS APC
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.35,61.44,fee schedule,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.78,24.576,fee schedule,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.6125,19.2,fee schedule,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.77,98.304,fee schedule,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.51,121.344,fee schedule,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.5105,24.43,fee schedule,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.4085,25.344,fee schedule,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.71,119.04,fee schedule,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.37,193.536,fee schedule,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,27.838,95.232,fee schedule,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,64.4315,241.472,fee schedule,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,59.142165,,,59.142165,6.25,92.88556,other,OPPS APC
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.072,274.944,other,OPPS APC
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,392.31084,,,392.31084,2.842,549.235176,other,OPPS APC
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,5.5,93.463636,other,OPPS APC
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,5.85,274.176,other,OPPS APC
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,5.29,274.176,other,OPPS APC
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,3.05,195.186327,other,OPPS APC
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,3.05,65.28,other,OPPS APC
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,392.31084,,,392.31084,3.91,549.235176,other,OPPS APC
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,9.71,238.848,other,OPPS APC
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,392.31084,,,392.31084,3.91,549.235176,other,OPPS APC
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,7.91,218.112,other,OPPS APC
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.31,272.64,other,OPPS APC
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.072,274.176,other,OPPS APC
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.45,274.176,other,OPPS APC
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,1.862,274.176,other,OPPS APC
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,1.302,263.69806,other,OPPS APC
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,1.932,416.02,other,OPPS APC
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,1.932,93.463636,other,OPPS APC
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,1.54,499.62884,other,OPPS APC
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.702,274.944,other,OPPS APC
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,2.072,608.812631,other,OPPS APC
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32.497835,,,32.497835,2.31,238.848,other,OPPS APC
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.31,416.02,other,OPPS APC
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.31,416.02,other,OPPS APC
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,2.31,238.848,other,OPPS APC
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32.497835,,,32.497835,1.68,229.632,other,OPPS APC
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.674,39.936,fee schedule,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,59.142165,,,59.142165,47.145,416.02,other,OPPS APC
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,59.142165,,,59.142165,34.124,116.736,other,OPPS APC
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.32,44.544,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,389.10344,,,389.10344,389.10344,4791.979,other,OPPS APC
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,43.3285,416.02,other,OPPS APC
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.3885,416.02,other,OPPS APC
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47.56116,,,47.56116,24.9195,416.02,other,OPPS APC
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,671.54688,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,671.54688,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.48,416.02,other,OPPS APC
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.48,416.02,other,OPPS APC
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.799745,416.02,other,OPPS APC
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.799745,416.02,other,OPPS APC
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.07683,416.02,other,OPPS APC
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.07683,416.02,other,OPPS APC
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,881.02656,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,881.02656,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,843.5712,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.135995,416.02,other,OPPS APC
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.135995,416.02,other,OPPS APC
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,54.47,416.02,other,OPPS APC
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,54.47,416.02,other,OPPS APC
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,566.10816,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,566.10816,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,492.14208,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,492.14208,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,252.787,1055.807021,other,OPPS APC
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,398.4875,1363.2,other,OPPS APC
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,3012.096,other,OPPS APC
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,3012.096,other,OPPS APC
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,168.824,1592,other,OPPS APC
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,305.32,1592,other,OPPS APC
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,417.629472,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,417.629472,,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,17.96,416.02,other,OPPS APC
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,163,975.36,other,OPPS APC
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,163,677.376,other,OPPS APC
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,123.475,422.4,other,OPPS APC
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,34.7975,416.02,other,OPPS APC
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,34.7975,416.02,other,OPPS APC
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,34.7975,416.02,other,OPPS APC
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,142.97,534.528,other,OPPS APC
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.5125,416.02,other,OPPS APC
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,60.3905,416.02,other,OPPS APC
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,51.635,416.02,other,OPPS APC
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,61.17,416.02,other,OPPS APC
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,32.328,416.02,other,OPPS APC
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,29.634,416.02,other,OPPS APC
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,116.5155,416.02,other,OPPS APC
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.8575,416.02,,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,21.3275,416.02,other,OPPS APC
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,28.0625,416.02,other,OPPS APC
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,80.5955,416.02,other,OPPS APC
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,112.25,416.02,other,OPPS APC
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,114.7195,416.02,other,OPPS APC
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,25.593,416.02,other,OPPS APC
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,128.12716,479.602522,other,OPPS APC
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.042,416.02,,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,36.369,416.02,,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,84.99,559.872,other,OPPS APC
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.01,416.02,other,OPPS APC
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,128.12716,662.784,other,OPPS APC
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,128.12716,662.784,other,OPPS APC
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,13488.384,other,OPPS APC
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13488.384,other,OPPS APC
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,25715.712,other,OPPS APC
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,25231.872,other,OPPS APC
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,25024.512,other,OPPS APC
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,20484.864,other,OPPS APC
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,20097.792,other,OPPS APC
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20484.864,other,OPPS APC
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,20097.792,other,OPPS APC
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,19712.256,other,OPPS APC
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,20097.792,other,OPPS APC
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,232.133,997.822944,other,OPPS APC
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,232.133,997.822944,other,OPPS APC
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,710.32455,,,710.32455,292.299,999.936,other,OPPS APC
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,710.32455,,,710.32455,399.86,1540.608,other,OPPS APC
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,710.32455,,,710.32455,399.86,1540.608,other,OPPS APC
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,173.5385,593.664,other,OPPS APC
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,2138.88,other,OPPS APC
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,2138.88,other,OPPS APC
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,169.4975,1592,other,OPPS APC
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,169.4975,1592,other,OPPS APC
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,13233.408,other,OPPS APC
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,25.49469,416.02,other,OPPS APC
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.286,416.02,fee schedule,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,108.8825,479.602522,other,OPPS APC
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,25.49469,416.02,other,OPPS APC
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.939,416.02,fee schedule,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,84.459332,416.02,other,OPPS APC
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,66.75974,416.02,other,OPPS APC
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.1435,416.02,fee schedule,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,41.157815,934.656,other,OPPS APC
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,41.157815,1442.304,other,OPPS APC
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,41.157815,416.02,other,OPPS APC
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32.497835,,,32.497835,23.39896,416.02,other,OPPS APC
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1223.3,other,OPPS APC
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1223.3,other,OPPS APC
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,281.81,1040.64,other,OPPS APC
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,281.81,1040.64,other,OPPS APC
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,943.104,other,OPPS APC
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,943.104,other,OPPS APC
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1354.752,other,OPPS APC
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1354.752,other,OPPS APC
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,336.9745,1152.768,other,OPPS APC
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.024,416.02,other,OPPS APC
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,72.5135,416.02,other,OPPS APC
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,86.208,416.02,other,OPPS APC
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,135.906309,571.392,other,OPPS APC
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1062.912,other,OPPS APC
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1062.912,other,OPPS APC
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1370.88,other,OPPS APC
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1370.88,other,OPPS APC
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.661,597.504,other,OPPS APC
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,241.7865,827.136,other,OPPS APC
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7960.32,other,OPPS APC
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2532.39,other,OPPS APC
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2532.39,other,OPPS APC
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1952.256,other,OPPS APC
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,228.541,1592,other,OPPS APC
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,114.495,1592,other,OPPS APC
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,228.541,1592,other,OPPS APC
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5638.7,other,OPPS APC
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1575.168,other,OPPS APC
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,40899.072,other,OPPS APC
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,40899.072,other,OPPS APC
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,40542.72,other,OPPS APC
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,40542.72,other,OPPS APC
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12978.432,fee schedule,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6909.98,other,OPPS APC
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4525.056,other,OPPS APC
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2361.6,other,OPPS APC
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1298.939725,,,1298.939725,399.86,2367.744,other,OPPS APC
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,399.86,2367.744,other,OPPS APC
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10671.09667,other,OPPS APC
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,325.997845,,,325.997845,73.54,934.656,other,OPPS APC
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,144.21845,,,144.21845,57.2475,416.02,other,OPPS APC
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,144.21845,,,144.21845,60.8395,416.02,other,OPPS APC
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,255.2565,873.216,other,OPPS APC
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.086,686,other,OPPS APC
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,213.724,731.136,other,OPPS APC
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,135.906309,702.72,other,OPPS APC
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,121.132463,686,other,OPPS APC
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,135.906309,775.5705,other,OPPS APC
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,99.0045,686,other,OPPS APC
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,135.906309,686,other,OPPS APC
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,135.906309,686,other,OPPS APC
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,170.171,686,other,OPPS APC
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,170.171,686,other,OPPS APC
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,183.192,686,other,OPPS APC
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,93.841,686,other,OPPS APC
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.8815,686,other,OPPS APC
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,686,other,OPPS APC
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,66.2275,416.02,other,OPPS APC
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,100.127,479.602522,other,OPPS APC
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,163,710.4,other,OPPS APC
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,88.004,416.02,other,OPPS APC
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,88.004,416.02,other,OPPS APC
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,40.859,416.02,other,OPPS APC
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,232.78851,,,232.78851,59.92,416.02,other,OPPS APC
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,98.67,479.602522,other,OPPS APC
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,66.2275,416.02,other,OPPS APC
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,59.4925,416.02,other,OPPS APC
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.123,416.02,other,OPPS APC
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.205,416.02,other,OPPS APC
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,43.553,416.02,other,OPPS APC
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,43.553,416.02,other,OPPS APC
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,761,RC,,,outpatient,,,367,256.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,22.74,416.02,other,OPPS APC
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,370.2005,1266.432,other,OPPS APC
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,355.8325,1217.28,other,OPPS APC
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,355.8325,1217.28,other,OPPS APC
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,182.294,623.616,other,OPPS APC
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,215.071,735.744,other,OPPS APC
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,157.3745,538.368,other,OPPS APC
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,176.457,603.648,other,OPPS APC
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,151.5375,518.4,other,OPPS APC
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,151.5375,829.50194,other,OPPS APC
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.817,570,other,OPPS APC
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.817,570,other,OPPS APC
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,30.083,570,other,OPPS APC
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,30.083,570,other,OPPS APC
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.4295,570,other,OPPS APC
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.4295,570,other,OPPS APC
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,94.4,583.68,other,OPPS APC
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,94.4,570,other,OPPS APC
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,94.4,570,other,OPPS APC
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,197.3355,675.072,other,OPPS APC
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,156.252,534.528,other,OPPS APC
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,74.983,416.02,other,OPPS APC
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.9805,585.854902,other,OPPS APC
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,93.841,416.02,other,OPPS APC
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,29.634,585.854902,other,OPPS APC
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,41.0835,416.02,other,OPPS APC
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.4705,416.02,other,OPPS APC
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,16.16,416.02,other,OPPS APC
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,74.983,416.02,other,OPPS APC
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,69.3705,416.02,other,OPPS APC
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,23.5725,416.02,other,OPPS APC
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,68.0235,416.02,other,OPPS APC
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,49.839,416.02,other,OPPS APC
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,155.1295,530.688,other,OPPS APC
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,162.538,556.032,other,OPPS APC
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,41.9815,585.854902,other,OPPS APC
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,70.143083,517.481916,other,OPPS APC
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,147.4965,585.854902,other,OPPS APC
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,34.385146,416.02,other,OPPS APC
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.38,,,14.38,14.38,416.02,fee schedule,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,27.6135,416.02,fee schedule,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.73,,,14.73,14.73,416.02,fee schedule,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20.02,,,20.02,20.02,416.02,fee schedule,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.44,,,14.44,14.44,416.02,fee schedule,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.44,,,14.44,14.44,416.02,fee schedule,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.33,,,30.33,30.33,416.02,fee schedule,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.33,,,30.33,30.33,416.02,fee schedule,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34.85,,,34.85,25.8175,416.02,fee schedule,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34.85,,,34.85,25.8175,416.02,fee schedule,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.33,,,30.33,25.8175,416.02,fee schedule,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.89,,,27.89,27.89,416.02,fee schedule,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.89,,,27.89,27.89,416.02,fee schedule,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18.56,,,18.56,18.56,416.02,fee schedule,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18.56,,,18.56,18.56,416.02,fee schedule,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,103.7,,,103.7,58.37,416.02,fee schedule,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,103.7,,,103.7,58.37,416.02,fee schedule,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,103.7,,,103.7,58.37,416.02,fee schedule,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,72.14,,,72.14,51.8595,416.02,fee schedule,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,38.12,,,38.12,25.8175,416.02,fee schedule,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,33.86,,,33.86,25.8175,416.02,fee schedule,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,49.68,,,49.68,25.8175,416.02,fee schedule,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.33,,,43.33,23.348,416.02,fee schedule,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34.45,,,34.45,34.45,416.02,fee schedule,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.36,,,29.36,23.797,416.02,fee schedule,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16.66,,,16.66,11.674,416.02,fee schedule,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.635,416.02,other,OPPS APC
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,81.0445,416.02,other,OPPS APC
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,74.085,416.02,other,OPPS APC
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,70.044,416.02,other,OPPS APC
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,761,RC,,,outpatient,,,387,270.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,82.56,416.02,other,OPPS APC
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,761,RC,,,outpatient,,,573,401.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,126.37,473.871,other,OPPS APC
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,761,RC,,,outpatient,,,838,586.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,179.35,693.026,other,OPPS APC
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,146.954008,985.784,other,OPPS APC
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.1184,416.02,other,OPPS APC
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.1184,416.02,other,OPPS APC
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.1184,416.02,other,OPPS APC
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,761,RC,,,outpatient,,,394,275.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.2428,416.02,other,OPPS APC
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,761,RC,,,outpatient,,,394,275.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.2428,416.02,other,OPPS APC
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,761,RC,,,outpatient,,,373,261.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.2428,416.02,other,OPPS APC
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,761,RC,,,outpatient,,,431,301.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,90.68,416.02,other,OPPS APC
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,761,RC,,,outpatient,,,431,301.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,90.68,416.02,other,OPPS APC
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,761,RC,,,outpatient,,,467,326.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.8415,416.02,other,OPPS APC
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,761,RC,,,outpatient,,,467,326.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.8415,416.02,other,OPPS APC
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,761,RC,,,outpatient,,,829,580.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,169.273,685.583,other,OPPS APC
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,761,RC,,,outpatient,,,754,527.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,169.273,685.583,other,OPPS APC
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,968.49734,,,968.49734,318.748996,2424.576,other,OPPS APC
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,968.49734,,,968.49734,318.748996,2424.576,other,OPPS APC
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,204.5195,699.648,other,OPPS APC
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,204.5195,699.648,other,OPPS APC
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31.31797,,,31.31797,31.31797,416.02,other,OPPS APC
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31.31797,,,31.31797,31.31797,416.02,other,OPPS APC
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,173.763,2998,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,36.1445,2998,,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,22389.354,other,OPPS APC
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.0075,2998,,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,1477.69344,other,OPPS APC
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.30904,416.02,other,OPPS APC
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.850175,416.02,other,OPPS APC
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.025285,416.02,other,OPPS APC
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.025285,416.02,other,OPPS APC
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.025285,416.02,other,OPPS APC
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.025285,416.02,other,OPPS APC
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.401765,416.02,other,OPPS APC
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.401765,416.02,other,OPPS APC
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.99,416.02,other,OPPS APC
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.3553,416.02,other,OPPS APC
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.3553,416.02,other,OPPS APC
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.3553,416.02,other,OPPS APC
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.23,416.02,other,OPPS APC
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.98576,416.02,other,OPPS APC
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.98576,416.02,other,OPPS APC
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.94544,416.02,other,OPPS APC
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.94544,416.02,other,OPPS APC
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.94544,416.02,other,OPPS APC
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.94544,416.02,other,OPPS APC
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.121435,416.02,other,OPPS APC
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.121435,416.02,other,OPPS APC
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.692165,416.02,other,OPPS APC
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.206745,416.02,other,OPPS APC
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.206745,416.02,other,OPPS APC
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04041,416.02,other,OPPS APC
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04041,416.02,other,OPPS APC
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04041,416.02,other,OPPS APC
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04041,416.02,other,OPPS APC
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.913715,416.02,other,OPPS APC
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.913715,416.02,other,OPPS APC
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.913715,416.02,other,OPPS APC
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.913715,416.02,other,OPPS APC
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.67604,416.02,other,OPPS APC
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,416.02,other,OPPS APC
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,416.02,other,OPPS APC
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,416.02,other,OPPS APC
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.600005,416.02,other,OPPS APC
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.600005,416.02,other,OPPS APC
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.600005,416.02,other,OPPS APC
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.087465,416.02,other,OPPS APC
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.66833,416.02,other,OPPS APC
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.66833,416.02,other,OPPS APC
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.122795,416.02,other,OPPS APC
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.122795,416.02,other,OPPS APC
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.98009,416.02,other,OPPS APC
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.21357,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.12,416.02,other,OPPS APC
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.994945,416.02,other,OPPS APC
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,291.097925,929.69805,other,OPPS APC
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,72522.399,other,OPPS APC
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,72522.399,other,OPPS APC
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,247.50227,1378.95936,other,OPPS APC
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,247.50227,1378.95936,other,OPPS APC
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,247.50227,1378.95936,other,OPPS APC
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,144.095325,460.20645,other,OPPS APC
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23012.49024,other,OPPS APC
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23012.49024,other,OPPS APC
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23012.49024,other,OPPS APC
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23012.49024,other,OPPS APC
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.06164,416.02,other,OPPS APC
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.06164,416.02,other,OPPS APC
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.06164,416.02,other,OPPS APC
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.06164,416.02,other,OPPS APC
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46419.072,other,OPPS APC
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46419.072,other,OPPS APC
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46419.072,other,OPPS APC
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46419.072,other,OPPS APC
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2621.49888,other,OPPS APC
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2621.49888,other,OPPS APC
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2621.49888,other,OPPS APC
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2621.49888,other,OPPS APC
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7592.15526,other,OPPS APC
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7592.15526,other,OPPS APC
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7592.15526,other,OPPS APC
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6381.888,other,OPPS APC
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19676.26496,,,19676.26496,399.86,42246.08608,other,OPPS APC
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12724.19328,other,OPPS APC
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,170.294475,582.5664,other,OPPS APC
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.890315,416.02,other,OPPS APC
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.890315,416.02,other,OPPS APC
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.890315,416.02,other,OPPS APC
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.890315,416.02,other,OPPS APC
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1487.02215,other,OPPS APC
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.86,1724.0184,other,OPPS APC
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1479.062,other,OPPS APC
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.86,2573.3136,other,OPPS APC
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,77.228,836,other,OPPS APC
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.8808895,,,0.8808895,0.71,921.95328,other,OPPS APC
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.4,836.83584,other,OPPS APC
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.39,416.02,other,OPPS APC
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,,,,,3.39,416.02,other,OPPS APC
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,,,,,3.39,416.02,other,OPPS APC
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.39,416.02,other,OPPS APC
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.31,416.02,other,OPPS APC
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.31,416.02,other,OPPS APC
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.31,416.02,other,OPPS APC
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.36,1148.18304,other,OPPS APC
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.36,1148.18304,other,OPPS APC
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5136.79872,other,OPPS APC
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5136.79872,other,OPPS APC
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5136.79872,other,OPPS APC
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,182.24,5164.04736,other,OPPS APC
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,182.24,5164.04736,other,OPPS APC
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,182.24,5164.04736,other,OPPS APC
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41430.25152,other,OPPS APC
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41430.25152,other,OPPS APC
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41430.25152,other,OPPS APC
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41430.25152,other,OPPS APC
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,177.26,5164.08576,other,OPPS APC
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,177.26,5164.08576,other,OPPS APC
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.39,18739.8144,other,OPPS APC
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.39,18739.8144,other,OPPS APC
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.39,18739.8144,other,OPPS APC
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.39,18739.8144,other,OPPS APC
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21.562892,,,21.562892,18.2,1865.41824,other,OPPS APC
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21.562892,,,21.562892,18.2,1865.41824,other,OPPS APC
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,25024.512,other,OPPS APC
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,26025.216,other,OPPS APC
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,26025.216,other,OPPS APC
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,26025.216,other,OPPS APC
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,26025.216,other,OPPS APC
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,185.6615,1592,other,OPPS APC
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,386.589,2141,other,OPPS APC
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.349,1592,other,OPPS APC
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.3685,416.02,other,OPPS APC
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12.01,,,12.01,12.01,416.02,fee schedule,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.6745,6652,other,OPPS APC
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.6745,6652,other,OPPS APC
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,701.034545,,,701.034545,104.83,6652,other,OPPS APC
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,49.7570835,,,49.7570835,43.27,2936.50176,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2101.412877,,,2101.412877,336.23,7116.76416,other,OPPS APC
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2101.412877,,,2101.412877,336.23,7116.76416,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.3013095,,,2.3013095,1.61,416.02,other,OPPS APC
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.3013095,,,2.3013095,1.61,416.02,other,OPPS APC
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,256.044451,,,256.044451,215.38,15801.64608,other,OPPS APC
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,256.044451,,,256.044451,215.38,15801.64608,other,OPPS APC
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,231.3509075,,,231.3509075,194.92,2044.28544,other,OPPS APC
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.278507,,,7.278507,5.51,1270.70976,other,OPPS APC
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98,4260,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98,4260,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.51,416.02,other,OPPS APC
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.51,416.02,other,OPPS APC
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.51,416.02,other,OPPS APC
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.51,416.02,other,OPPS APC
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.84689,416.02,other,OPPS APC
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12.749415,,,12.749415,11.13,416.02,other,OPPS APC
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26.7187875,,,26.7187875,23.33,974.33088,other,OPPS APC
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26.7187875,,,26.7187875,23.33,974.33088,other,OPPS APC
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.82,416.02,other,OPPS APC
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.82,416.02,other,OPPS APC
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.82,416.02,other,OPPS APC
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.82,416.02,other,OPPS APC
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.38,416.02,other,OPPS APC
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,62.0276795,,,62.0276795,50.93,4488.66816,other,OPPS APC
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,62.0276795,,,62.0276795,50.93,4488.66816,other,OPPS APC
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.23144,416.02,other,OPPS APC
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.23144,416.02,other,OPPS APC
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.23144,416.02,other,OPPS APC
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22.3635965,,,22.3635965,15.67,697.86624,other,OPPS APC
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22.3635965,,,22.3635965,15.67,697.86624,other,OPPS APC
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.338073,,,7.338073,6.15,1343.87712,other,OPPS APC
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.03,416.02,other,OPPS APC
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.03,416.02,other,OPPS APC
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.06,416.02,other,OPPS APC
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.06,416.02,other,OPPS APC
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6971.878415,,,6971.878415,60.43,12645.75744,other,OPPS APC
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6971.878415,,,6971.878415,60.43,12645.75744,other,OPPS APC
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0446745,,,0.0446745,0.04,416.02,other,OPPS APC
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0446745,,,0.0446745,0.04,416.02,other,OPPS APC
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1343.739085,,,1343.739085,399.86,2155.44576,other,OPPS APC
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1343.739085,,,1343.739085,399.86,2155.44576,other,OPPS APC
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.68951,416.02,other,OPPS APC
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.68951,416.02,other,OPPS APC
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.68951,416.02,other,OPPS APC
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.44333,,,1.44333,1.22,416.02,other,OPPS APC
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.44333,,,1.44333,1.22,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9.427465,,,9.427465,7.54,500.98176,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.96,416.02,other,OPPS APC
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.96,416.02,other,OPPS APC
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.65,416.02,other,OPPS APC
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,115.216681,,,115.216681,92.48,1248.58368,other,OPPS APC
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,115.216681,,,115.216681,92.48,1248.58368,other,OPPS APC
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.15189,416.02,other,OPPS APC
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.15189,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.74271,416.02,other,OPPS APC
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.74271,416.02,other,OPPS APC
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.74271,416.02,other,OPPS APC
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.86,416.02,other,OPPS APC
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.86,416.02,other,OPPS APC
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.86,416.02,other,OPPS APC
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.40333,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.61749,416.02,other,OPPS APC
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.61749,416.02,other,OPPS APC
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.61749,416.02,other,OPPS APC
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17.883546,,,17.883546,14.7,4668.927562,other,OPPS APC
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.03,416.02,other,OPPS APC
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.03,416.02,other,OPPS APC
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.03,416.02,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.808809,,,4.808809,0.46,416.02,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.808809,,,4.808809,0.46,416.02,other,OPPS APC
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.63,416.02,other,OPPS APC
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.78,416.02,other,OPPS APC
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.78,416.02,other,OPPS APC
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.88268,,,30.88268,24.19,6805.34016,other,OPPS APC
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.88268,,,30.88268,24.19,6805.34016,other,OPPS APC
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.03,416.02,other,OPPS APC
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.295505,416.02,other,OPPS APC
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.295505,416.02,other,OPPS APC
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.295505,416.02,other,OPPS APC
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.29108,416.02,other,OPPS APC
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.29108,416.02,other,OPPS APC
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.29108,416.02,other,OPPS APC
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.28219,416.02,other,OPPS APC
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.28219,416.02,other,OPPS APC
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.28219,416.02,other,OPPS APC
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5599.323132,,,5599.323132,399.86,9367.9104,other,OPPS APC
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,100.224377,,,100.224377,87.49,442.10688,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.3402,416.02,other,OPPS APC
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,820.0645955,,,820.0645955,399.86,1422.7584,other,OPPS APC
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.763505,945.2928,other,OPPS APC
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.763505,945.2928,other,OPPS APC
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.763505,945.2928,other,OPPS APC
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.763505,945.2928,other,OPPS APC
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.78,416.02,other,OPPS APC
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.78,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.3171015,,,257.3171015,224.63,13826.65728,other,OPPS APC
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.86,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,74.8916445,,,74.8916445,52.988735,416.02,other,OPPS APC
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,74.8916445,,,74.8916445,52.988735,416.02,other,OPPS APC
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,438.481363,,,438.481363,339.74932,1162.26048,other,OPPS APC
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.2611955,,,1.2611955,1.1,1903.32672,other,OPPS APC
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.3781655,,,7.3781655,7.3781655,1590,other,OPPS APC
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.3781655,,,7.3781655,7.3781655,1590,other,OPPS APC
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,1056.72192,other,OPPS APC
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,1056.72192,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,57.105466,,,57.105466,48.47,416.02,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,57.105466,,,57.105466,48.47,416.02,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.1237725,,,56.1237725,44.12,1447.31904,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.1237725,,,56.1237725,44.12,1447.31904,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,36.41,416.02,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.28,416.02,other,OPPS APC
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.28,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,666.4255535,,,666.4255535,333.276985,1140.11904,other,OPPS APC
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,666.4255535,,,666.4255535,333.276985,1140.11904,other,OPPS APC
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.56878,416.02,other,OPPS APC
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.56878,416.02,other,OPPS APC
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.56878,416.02,other,OPPS APC
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.56878,416.02,other,OPPS APC
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,27.14,416.02,other,OPPS APC
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,276.5271365,,,276.5271365,85.36837,416.02,other,OPPS APC
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.9114465,,,36.9114465,32.22,2399.94624,other,OPPS APC
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20.2398395,,,20.2398395,17.18,416.02,other,OPPS APC
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20.2398395,,,20.2398395,17.18,416.02,other,OPPS APC
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21,416.02,other,OPPS APC
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21,416.02,other,OPPS APC
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21,416.02,other,OPPS APC
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21,416.02,other,OPPS APC
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.83,416.02,other,OPPS APC
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.83,416.02,other,OPPS APC
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.410089,,,0.410089,0.36,416.02,other,OPPS APC
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.410089,,,0.410089,0.36,416.02,other,OPPS APC
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,114.43,1432.33536,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,114.43,1432.33536,,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.12259,,,1.12259,1,1207.54176,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8683105,,,1.8683105,1.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8683105,,,1.8683105,1.24,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1853.014639,,,1853.014639,399.86,10964.15232,other,OPPS APC
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1853.014639,,,1853.014639,399.86,10964.15232,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.30786,416.02,other,OPPS APC
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.30786,416.02,other,OPPS APC
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34.8632925,,,34.8632925,29.75,6255.52128,other,OPPS APC
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.18518,416.02,other,OPPS APC
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.18518,416.02,other,OPPS APC
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.18518,416.02,other,OPPS APC
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.18518,416.02,other,OPPS APC
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.07677,,,1.07677,1.07677,506.21952,other,OPPS APC
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.18,416.02,other,OPPS APC
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.18,416.02,other,OPPS APC
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.41,416.02,other,OPPS APC
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.41,416.02,other,OPPS APC
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.41,416.02,other,OPPS APC
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.41,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.46,1022.48448,other,OPPS APC
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.46,1022.48448,other,OPPS APC
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.46,1022.48448,other,OPPS APC
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.46,1022.48448,other,OPPS APC
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.72,416.02,other,OPPS APC
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.72,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.317135,416.02,other,OPPS APC
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.317135,416.02,other,OPPS APC
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.54,416.02,other,OPPS APC
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.54,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.263845,416.02,other,OPPS APC
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.263845,416.02,other,OPPS APC
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,other,OPPS APC
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3988.807407,,,3988.807407,399.86,45671.09376,other,OPPS APC
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.01,416.02,other,OPPS APC
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.01,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.739875,416.02,other,OPPS APC
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.739875,416.02,other,OPPS APC
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.89655,416.02,other,OPPS APC
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.89655,416.02,other,OPPS APC
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.89655,416.02,other,OPPS APC
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.89655,416.02,other,OPPS APC
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.20861,,,6.20861,5.42,416.02,other,OPPS APC
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.20861,,,6.20861,5.42,416.02,other,OPPS APC
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.40469,416.02,other,OPPS APC
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.586535,416.02,other,OPPS APC
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.586535,416.02,other,OPPS APC
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.43,416.02,other,OPPS APC
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.43,416.02,other,OPPS APC
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.95,416.02,other,OPPS APC
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.95,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.136465,,,7.136465,7.136465,1471.59552,other,OPPS APC
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.136465,,,7.136465,7.136465,1471.59552,other,OPPS APC
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,425.3161315,,,425.3161315,357.36,11800.75008,other,OPPS APC
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,425.3161315,,,425.3161315,357.36,11800.75008,other,OPPS APC
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.88,455.8464,other,OPPS APC
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.88,455.8464,other,OPPS APC
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.88,455.8464,other,OPPS APC
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,,,other,OPPS APC
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,,,other,OPPS APC
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,,,other,OPPS APC
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39.331888,,,39.331888,33.71,3005.13792,other,OPPS APC
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39.331888,,,39.331888,33.71,3005.13792,other,OPPS APC
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12.9430045,,,12.9430045,10.7,2359.38048,other,OPPS APC
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12.9430045,,,12.9430045,10.7,2359.38048,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
ROMIPLOSTIM 125 MCG SC SOLR|DISCARDED DRUG NOT ADMINISTERED,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,179.925976,,,179.925976,139.22,12730.14528,other,OPPS APC
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,179.925976,,,179.925976,139.22,12730.14528,other,OPPS APC
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.12,416.02,other,OPPS APC
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.12,416.02,other,OPPS APC
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.12,416.02,other,OPPS APC
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.12,416.02,other,OPPS APC
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.57,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,180.672842,,,180.672842,152.7,14884.48512,other,OPPS APC
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.358225,416.02,other,OPPS APC
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.358225,416.02,other,OPPS APC
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.358225,416.02,other,OPPS APC
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.358225,416.02,other,OPPS APC
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.63291,416.02,other,OPPS APC
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.63291,416.02,other,OPPS APC
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.63291,416.02,other,OPPS APC
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.63291,416.02,other,OPPS APC
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2375.012116,,,2375.012116,399.86,4191.12192,other,OPPS APC
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52,416.02,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,44.72489,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.9,416.02,other,OPPS APC
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.9,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25.49883,,,25.49883,22.26,18370.38336,other,OPPS APC
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.41,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.528165,416.02,other,OPPS APC
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.528165,416.02,other,OPPS APC
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.15,416.02,other,OPPS APC
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.15,416.02,other,OPPS APC
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.15,416.02,other,OPPS APC
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.15,416.02,other,OPPS APC
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5.7653015,,,5.7653015,5.69,1897.8816,other,OPPS APC
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.36,416.02,other,OPPS APC
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.36,416.02,other,OPPS APC
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.36,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.51,416.02,other,OPPS APC
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.51,416.02,other,OPPS APC
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.43,416.02,other,OPPS APC
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.43,416.02,other,OPPS APC
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.47,416.02,other,OPPS APC
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.47,416.02,other,OPPS APC
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.47,416.02,other,OPPS APC
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10347.43296,other,OPPS APC
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.54,416.02,other,OPPS APC
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.54,416.02,other,OPPS APC
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.14,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.62,416.02,other,OPPS APC
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.23,416.02,other,OPPS APC
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.23,416.02,other,OPPS APC
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.39,416.02,other,OPPS APC
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.39,416.02,other,OPPS APC
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.39,416.02,other,OPPS APC
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.39,416.02,other,OPPS APC
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.89986,416.02,other,OPPS APC
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.568211,,,2.568211,2.568211,4642.0992,other,OPPS APC
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.568211,,,2.568211,2.568211,4642.0992,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.46624,,,1.46624,1.26,2225.664,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.46624,,,1.46624,1.26,2225.664,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.773234,,,1.773234,1.25,2861.568,other,OPPS APC
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.773234,,,1.773234,1.25,2861.568,other,OPPS APC
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.4136115,,,4.4136115,3.35,3804.8256,other,OPPS APC
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.4136115,,,4.4136115,3.35,3804.8256,other,OPPS APC
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.685052,,,2.685052,1.94,10651.392,other,OPPS APC
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,73.22,786.36288,other,OPPS APC
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.536555,416.02,other,OPPS APC
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.536555,416.02,other,OPPS APC
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.32,416.02,other,OPPS APC
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.5922235,,,0.5922235,0.52,416.02,other,OPPS APC
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.5922235,,,0.5922235,0.52,416.02,other,OPPS APC
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,87.818612,,,87.818612,69.53663,416.02,other,OPPS APC
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,87.818612,,,87.818612,69.53663,416.02,other,OPPS APC
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.2464545,,,8.2464545,7.2,2367.72096,other,OPPS APC
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.2464545,,,8.2464545,7.2,2367.72096,other,OPPS APC
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.32,416.02,other,OPPS APC
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.32,416.02,other,OPPS APC
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.2212105,,,6.2212105,5.43,2152.77312,other,OPPS APC
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.2212105,,,6.2212105,5.43,2152.77312,other,OPPS APC
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.829643,,,14.829643,12.95,3900.27264,other,OPPS APC
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,83.282432,,,83.282432,72.7,7001.856,other,OPPS APC
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,83.282432,,,83.282432,72.7,7001.856,other,OPPS APC
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.931495,416.02,other,OPPS APC
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.931495,416.02,other,OPPS APC
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.800726,,,1.800726,1.57,905.322979,other,OPPS APC
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.800726,,,1.800726,1.57,905.322979,other,OPPS APC
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,274.755048,,,274.755048,221.96,24824.61696,other,OPPS APC
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,247.9492025,,,247.9492025,206.03,30463.31136,other,OPPS APC
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.41,416.02,other,OPPS APC
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.41,416.02,other,OPPS APC
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.7904535,,,56.7904535,47.04,6870.26688,other,OPPS APC
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,86.4611945,,,86.4611945,72.08,3359.0784,other,OPPS APC
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,86.4611945,,,86.4611945,72.08,3359.0784,other,OPPS APC
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.37,416.02,other,OPPS APC
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16.3176475,,,16.3176475,14.25,416.02,other,OPPS APC
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.69078,416.02,other,OPPS APC
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.69078,416.02,other,OPPS APC
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.783608,,,4.783608,4.18,1339.56096,other,OPPS APC
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.783608,,,4.783608,4.18,1339.56096,other,OPPS APC
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.34,416.02,other,OPPS APC
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,155.5417175,,,155.5417175,128.78,3097.0368,other,OPPS APC
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,153.673407,,,153.673407,62.498555,604.75,other,OPPS APC
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.83,416.02,other,OPPS APC
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.83,416.02,other,OPPS APC
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.83,416.02,other,OPPS APC
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.79,416.02,other,OPPS APC
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.79,416.02,other,OPPS APC
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.79,416.02,other,OPPS APC
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.79,416.02,other,OPPS APC
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,772.951326,,,772.951326,399.86,5828.5824,other,OPPS APC
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,772.951326,,,772.951326,399.86,5828.5824,other,OPPS APC
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,416.02,other,OPPS APC
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,416.02,other,OPPS APC
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,416.02,other,OPPS APC
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,153.5622935,,,153.5622935,122.55,12759.31392,other,OPPS APC
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,153.5622935,,,153.5622935,122.55,12759.31392,other,OPPS APC
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.67,416.02,other,OPPS APC
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.67,416.02,other,OPPS APC
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,27.33512,416.02,other,OPPS APC
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.620622,,,202.620622,167.93,74965.60128,other,OPPS APC
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.620622,,,202.620622,167.93,74965.60128,other,OPPS APC
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.47721,416.02,other,OPPS APC
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.47721,416.02,other,OPPS APC
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,83.0796785,,,83.0796785,72.53,1721.82528,other,OPPS APC
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15.285552,,,15.285552,12.06,3366.45888,other,OPPS APC
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2911.602117,,,2911.602117,399.86,4898.21952,other,OPPS APC
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.686428,,,66.686428,54.81,12451.14624,other,OPPS APC
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,62.6027205,,,62.6027205,29.06,416.02,other,OPPS APC
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,85.440554,,,85.440554,70.55,18103.04256,other,OPPS APC
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,182.507933,,,182.507933,149.71,14042.8032,other,OPPS APC
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,182.507933,,,182.507933,149.71,14042.8032,other,OPPS APC
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.792772,,,4.792772,4.18,8613.9648,other,OPPS APC
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.792772,,,4.792772,4.18,8613.9648,other,OPPS APC
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18.463169,,,18.463169,15.37,14335.95648,other,OPPS APC
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,428.151244,,,428.151244,356.51,15644.98176,other,OPPS APC
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,81.4118305,,,81.4118305,68.87,15685.39392,other,OPPS APC
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,81.4118305,,,81.4118305,68.87,15685.39392,other,OPPS APC
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,88.563187,,,88.563187,77.31,10318.18752,other,OPPS APC
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,88.563187,,,88.563187,77.31,10318.18752,other,OPPS APC
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,424.045772,,,424.045772,223.44,900.08832,other,OPPS APC
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.896555,,,36.896555,32.21,4261.85472,other,OPPS APC
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,other,OPPS APC
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,46.3297475,,,46.3297475,38.33,13677.02016,other,OPPS APC
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,46.3297475,,,46.3297475,38.33,13677.02016,other,OPPS APC
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,89.28027,,,89.28027,77.94,3651.07968,other,OPPS APC
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,89.28027,,,89.28027,77.94,3651.07968,other,OPPS APC
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.95,416.02,other,OPPS APC
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.49,416.02,other,OPPS APC
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.49,416.02,other,OPPS APC
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.59,416.02,other,OPPS APC
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7115,,,60.7115,1.65,1060,other,OPPS APC
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7115,,,60.7115,1.65,1060,other,OPPS APC
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.2,,,29.2,4.41367,416.02,fee schedule,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.2,,,29.2,4.41367,416.02,fee schedule,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.2,,,29.2,4.41367,416.02,fee schedule,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.2,,,29.2,4.41367,416.02,fee schedule,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.34,,,873.34,110.03643,1222.676,fee schedule,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.34,,,873.34,110.03643,1222.676,fee schedule,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.34,,,873.34,110.03643,1222.676,fee schedule,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,101.16,,,101.16,23.579235,416.02,fee schedule,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,101.16,,,101.16,23.579235,416.02,fee schedule,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,101.16,,,101.16,23.579235,416.02,fee schedule,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,101.16,,,101.16,23.579235,416.02,fee schedule,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,185.48,,,185.48,16.49177,416.02,fee schedule,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,185.48,,,185.48,16.49177,416.02,fee schedule,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,185.48,,,185.48,16.49177,416.02,fee schedule,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,261.35,,,261.35,31.76675,416.02,fee schedule,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,261.35,,,261.35,31.76675,416.02,fee schedule,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,261.35,,,261.35,31.76675,416.02,fee schedule,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,261.35,,,261.35,31.76675,416.02,fee schedule,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,335.72,,,335.72,335.72,5377.9968,fee schedule,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.86,,,124.86,15.326615,416.02,fee schedule,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.86,,,124.86,15.326615,416.02,fee schedule,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.86,,,124.86,15.326615,416.02,fee schedule,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.18,,,56.18,17.225885,416.02,fee schedule,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.18,,,56.18,17.225885,416.02,fee schedule,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.18,,,56.18,17.225885,416.02,fee schedule,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20.61,,,20.61,20.61,416.02,fee schedule,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,125.65,,,125.65,125.65,1058.40384,fee schedule,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,125.65,,,125.65,125.65,1058.40384,fee schedule,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3409.78176,other,OPPS APC
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,252.25,3748.3008,other,OPPS APC
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,252.25,3748.3008,other,OPPS APC
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.737705,686.06,other,OPPS APC
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3534.81216,other,OPPS APC
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3534.81216,other,OPPS APC
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,401.49775,,,401.49775,326.6475,1117.44,other,OPPS APC
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,68.581085,,,68.581085,49.4,942.336,other,OPPS APC
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,207.12931,,,207.12931,123.6995,423.168,other,OPPS APC
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,91.59418,,,91.59418,71.53,416.02,other,OPPS APC
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,156.372205,,,156.372205,105.7395,416.02,other,OPPS APC
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,454.90096,,,454.90096,163,871.3328,other,OPPS APC
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,149.92304,,,149.92304,136.61,1072.896,other,OPPS APC
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,264.186665,,,264.186665,163,1384.1308,other,OPPS APC
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,541.054015,,,541.054015,163,1119.53,other,OPPS APC
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,770.32584,,,770.32584,163,1476.21,other,OPPS APC
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,356.376505,,,356.376505,163,2191.8936,other,OPPS APC
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,289.21584,,,289.21584,142.782,598.2,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,825.527485,,,825.527485,163,1698,other,OPPS APC
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,564.38785,,,564.38785,163,1747.7512,other,OPPS APC
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,277.05063,,,277.05063,163,1046.786,other,OPPS APC
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,83.128935,,,83.128935,49.839,416.02,other,OPPS APC
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,631.49124,,,631.49124,163,1265.41,other,OPPS APC
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,19.9805,416.02,other,OPPS APC
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.387179,,,0.387179,0.34,726.30528,other,OPPS APC
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,416.02,other,OPPS APC
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,416.02,other,OPPS APC
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,152.44314,,,152.44314,87.98,1653.428703,other,OPPS APC
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,152.44314,,,152.44314,87.98,1653.428703,other,OPPS APC
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,348.861775,3862.93248,other,OPPS APC
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,348.861775,3862.93248,other,OPPS APC
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,348.861775,3862.93248,other,OPPS APC
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,348.861775,3862.93248,other,OPPS APC
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,30.42,6716.16,other,OPPS APC
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.25,659.42016,other,OPPS APC
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.25,659.42016,other,OPPS APC
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.96,24594.91584,other,OPPS APC
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.96,24594.91584,other,OPPS APC
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.96,24594.91584,other,OPPS APC
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,8051.0208,other,OPPS APC
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,8051.0208,other,OPPS APC
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,8051.0208,other,OPPS APC
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,46.98,6518.784,other,OPPS APC
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.16,4034.304,other,OPPS APC
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.16,4034.304,other,OPPS APC
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.4745,3643.99872,other,OPPS APC
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.4745,3643.99872,other,OPPS APC
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.4745,3643.99872,other,OPPS APC
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.4745,3643.99872,other,OPPS APC
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,102.28,3422.3616,other,OPPS APC
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,102.28,3422.3616,other,OPPS APC
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15.599419,,,15.599419,13.62,1653.428703,other,OPPS APC
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31.136981,,,31.136981,27.18,1653.428703,other,OPPS APC
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31.136981,,,31.136981,27.18,1653.428703,other,OPPS APC
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,38.481927,,,38.481927,33.59,7269.974281,other,OPPS APC
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,38.481927,,,38.481927,33.59,7269.974281,other,OPPS APC
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,24.387695,,,24.387695,21.29,1590.89664,other,OPPS APC
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.92,438.4896,other,OPPS APC
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.92,438.4896,other,OPPS APC
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.56,416.02,other,OPPS APC
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.56,416.02,other,OPPS APC
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.38,416.02,other,OPPS APC
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.38,416.02,other,OPPS APC
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.38,416.02,other,OPPS APC
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.38,416.02,other,OPPS APC
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9.775697,,,9.775697,9.53,2181.7344,other,OPPS APC
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9.775697,,,9.775697,9.53,2181.7344,other,OPPS APC
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3992.7552,other,OPPS APC
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3992.7552,other,OPPS APC
Bilateral procedure,,,,,,,,,,,,,,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,525.9295,1261.6,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,808.0705,1938.4,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,731.3655,1754.4,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1108.2205,2658.4,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,594.6305,2483,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,444.5555,1066.4,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,398.5325,956,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1337.0015,3207.2,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1215.941,2916.8,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,672.0025,1612,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1604.135,3848,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.205,72,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.491,94.4,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.3685,90.4,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,17.96,64,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,17.7355,63.2,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,59.9415,213.6,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.205,72,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.309,225.6,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.166,214.4,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.5335,226.4,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.9825,228,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,64.4315,229.6,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,68.9215,245.6,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,94.9635,338.4,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,98.331,350.4,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,118.7605,423.2,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,118.7605,423.2,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,183.192,652.8,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,871.958,3107.2,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1098.0295,3912.8,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1176.829,4193.6,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1227.117,4372.8,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,149.7415,533.6,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.2485,282.4,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,73.4115,261.6,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,87.555,312,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,158.7215,565.6,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,32.328,122.0544,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,58.819,222.0712,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,61.064,230.5472,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,68.697,259.3656,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,84.6365,319.5452,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,105.7395,399.2196,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,110.005,415.324,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,210.8055,795.8964,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.756,74.5888,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.3275,80.522,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.246,91.5408,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,28.736,108.4928,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,43.3285,163.5868,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,43.7775,165.282,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.5125,190.71,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.1465,302.5932,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.1465,302.5932,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.1465,302.5932,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,83.963,317.0024,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,88.902,335.6496,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,90.249,340.7352,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,91.8205,346.6684,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,93.841,354.2968,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,93.6165,353.4492,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.127,378.0296,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,101.2495,382.2676,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.617,394.9816,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.617,394.9816,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,105.515,398.372,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.556,413.6288,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,115.842,437.3616,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,116.5155,439.9044,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,117.4135,443.2948,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,121.4545,458.5516,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,121.4545,458.5516,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,124.822,471.2656,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,151.313,571.2824,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.803,588.2344,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.803,588.2344,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.803,588.2344,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.8235,595.8628,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,161.4155,609.4244,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,162.089,611.9672,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,164.1095,619.5956,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,171.7425,648.414,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.212,657.7376,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.212,657.7376,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,189.7025,716.222,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,189.7025,716.222,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,189.7025,716.222,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.9275,758.602,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.9275,758.602,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,185.6615,700.9652,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,210.8055,795.8964,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,219.7855,829.8004,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,354.9345,1340.0556,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,354.9345,1340.0556,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,255.032,962.8736,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,284.8905,1075.6044,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,296.1155,1117.9844,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,314.0755,1185.7924,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,316.096,1193.4208,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,455.0615,1718.0852,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,498.1655,1880.8244,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,584.149,2205.4552,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,660.7035,2494.4868,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1249.3425,4716.894,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1237.444,4671.9712,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,924.94,3492.112,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1237.444,4671.9712,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,302.8505,1143.4124,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.7555,33.0564,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,277.931,1049.3288,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,249.8685,943.3788,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,423.6315,1599.4212,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,246.2765,929.8172,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,337.648,1274.7904,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,71.6155,270.3844,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,103.719,391.5912,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,241.7865,912.8652,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.107,411.9336,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.3515,378.8772,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,299.034,1129.0032,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,66.6765,251.7372,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,120.5565,455.1612,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,126.8425,478.894,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,93.6165,353.4492,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,92.494,349.2112,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.1295,585.6916,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,113.597,428.8856,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,95.188,359.3824,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,133.353,503.4744,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,118.7605,448.3804,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,203.397,767.9256,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.476,549.2448,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,222.255,839.124,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,194.1925,733.174,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,97.2085,367.0108,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,88.453,333.9544,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,136.047,513.6456,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.15,593.32,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,495.0225,1868.958,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,299.932,1132.3936,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,245.603,927.2744,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,266.706,1006.9488,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,259.073,978.1304,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,259.073,978.1304,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,176.2325,665.366,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.8855,660.2804,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,267.3795,1009.4916,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,220.6835,833.1908,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,102.5965,387.3532,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,105.7395,399.2196,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.3925,394.134,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,184.7635,697.5748,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,138.9655,524.6644,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,178.4775,673.842,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,162.089,611.9672,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,55.0025,207.662,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,214.173,808.6104,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,259.073,978.1304,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,111.5765,421.2572,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,56.3495,212.7476,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,91.596,345.8208,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.3515,378.8772,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.5955,304.2884,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.044,264.4512,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.044,264.4512,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,139.639,527.2072,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,123.924,467.8752,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,274.1145,1034.9196,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,846.814,3197.1472,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,438.673,1656.2104,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,854.447,3225.9656,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,148.3945,560.2636,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.965,483.132,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.965,483.132,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,759.9325,2869.126,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,715.0325,2699.606,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,85.31,322.088,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.8855,660.2804,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,74.085,279.708,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,85.759,323.7832,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.576,379.7248,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.1885,400.9148,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.699,425.4952,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,147.721,557.7208,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,148.3945,560.2636,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.8235,595.8628,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,167.2525,631.462,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,176.2325,665.366,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,202.2745,763.6876,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,205.4175,775.554,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,250.7665,946.7692,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,574.72,2169.856,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,574.72,2169.856,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,667.663,2520.7624,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,675.9695,2552.1236,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,675.9695,2552.1236,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,710.5425,2682.654,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,767.341,2897.0968,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,777.219,2934.3912,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1481.0265,5591.6172,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,147.721,557.7208,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,147.721,557.7208,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,276.584,1044.2432,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,392.875,1483.3,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,882.9585,3333.6108,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,923.593,3487.0264,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1001.4945,3781.1436,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.617,394.9816,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,667.663,2520.7624,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,667.663,2520.7624,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,667.663,2520.7624,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,238.419,900.1512,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,238.419,900.1512,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,238.419,900.1512,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,324.4025,1224.782,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.576,379.7248,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,77.9015,294.1172,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,239.0925,902.694,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.2485,299.2028,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,317.2185,1197.6588,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,289.605,1093.404,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,289.605,1093.404,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,479.3075,1809.626,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,167.2525,631.462,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,58.819,222.0712,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,58.819,222.0712,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.2485,299.2028,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,288.707,1090.0136,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.7005,550.0924,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,170.171,642.4808,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,238.6435,900.9988,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,245.3785,926.4268,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,273.2165,1031.5292,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,304.1975,1148.498,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,313.851,1184.9448,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,330.913,1249.3624,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,336.5255,1270.5524,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,398.0385,1502.7948,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,355.8325,1343.446,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,367.282,1386.6736,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,392.6505,1482.4524,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.413,401.7624,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.413,401.7624,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.413,401.7624,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,73.636,278.0128,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.107,411.9336,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,398.0385,1502.7948,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.803,588.2344,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.413,401.7624,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.6375,402.61,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,383.895,1449.396,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,297.9115,1124.7652,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,297.9115,1124.7652,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,291.85,1101.88,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.184,27.1232,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.879,120.3592,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,35.2465,133.0732,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.124,128.8352,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,46.696,176.3008,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.47,50.856,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.8375,63.57,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.47,50.856,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.8375,63.57,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2255,83.9124,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.43,118.664,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,30.981,116.9688,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,35.6955,134.7684,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.15,593.32,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,190.825,720.46,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,373.119,1408.7112,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,213.275,805.22,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,656.438,2478.3824,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,269.4,1017.12,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,956.819,3612.4712,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2057.767,7769.1016,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,269.4,1017.12,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,841.6505,3177.6524,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1202.422,4539.7456,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2164.4045,8171.7116,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.6125,21.19,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.939,18.6472,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.1635,19.4948,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.286,23.7328,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.5105,24.5804,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.4085,27.9708,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.531,32.2088,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,336.75,1271.4,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.6745,6652,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.7405,482.2844,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.7405,482.2844,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.5105,24.5804,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.5715,163,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.6535,163,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,38.3895,163,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9291.52,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6297.984,,
Heart Transplant Or Implant Of Heart Assist System With McC,1,MS-DRG,,,,,,,inpatient,,,509415.58,356590.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,249067.5832,,,249067.5832,7771.48,570763.9296,case rate,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,495073.43,346551.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,189560.4996,,,189560.4996,7771.48,434261.5728,case rate,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,347238.19,243066.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,125063.5024,,,125063.5024,7771.48,286312.0824,case rate,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,111379.6,77965.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47912.84716,,,47912.84716,7771.48,109336.4384,case rate,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,80508.95,56356.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39754.43987,,,39754.43987,7771.48,90620.608,case rate,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,64638.3,45246.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,53951.26988,,,53951.26988,7771.48,123186.8824,case rate,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,31748.36,22223.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29900.04491,,,29900.04491,7771.48,68016.116,case rate,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,38853.43,27197.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19906.96764,,,19906.96764,7771.48,45091.4528,case rate,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,36305.14,25413.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14342.89147,,,14342.89147,7771.48,32329.1856,case rate,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,66447.77,46513.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34599.34405,,,34599.34405,7771.48,78796.564,case rate,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,67076.27,46953.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20343.33113,,,20343.33113,7771.48,53661.016,case rate,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,60360.78,42252.546,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16441.67619,,,16441.67619,7771.48,48288.624,case rate,
Extracranial Procedures With McC,37,MS-DRG,,,,,,,inpatient,,,89958.63,62971.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29583.81388,,,29583.81388,7771.48,71966.904,case rate,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,41578.78,29105.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14482.45712,,,14482.45712,7771.48,33263.024,case rate,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,33795.18,23656.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10303.43753,,,10303.43753,7771.48,27036.144,case rate,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,68215.86,47751.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20196.69887,,,20196.69887,7771.48,54572.688,case rate,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,26930.4,18851.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13491.36433,,,13491.36433,7771.48,30377.7624,case rate,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,21358.75,14951.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9886.507232,,,9886.507232,7123.143125,22105.9976,case rate,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,44783.08,31348.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22368.79972,,,22368.79972,7771.48,50741.056,case rate,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,47305.96,33114.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12036.52492,,,12036.52492,7771.48,37844.768,case rate,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,15006.39,10504.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16554.74204,,,16554.74204,5004.631065,37401.2648,case rate,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,24159.04,16911.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11057.79871,,,11057.79871,7771.48,24793.004,case rate,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,28159.44,19711.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8132.219999,,,8132.219999,6624.72,22527.552,case rate,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,89978.5,62984.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,24129.27025,,,24129.27025,7771.48,71982.8,case rate,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,41764.16,29234.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15980.57955,,,15980.57955,7771.48,36086.1312,case rate,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,42817.54,29972.278,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12658.38706,,,12658.38706,7771.48,34254.032,case rate,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,29171.68,20420.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17820.54949,,,17820.54949,7771.48,40307.1224,case rate,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20113.63,14079.541,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9231.961995,,,9231.961995,6707.895605,20608.488,case rate,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,15729.11,11010.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6329.349786,,,6329.349786,5143.64,13947.7112,case rate,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,46442.5,32509.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13100.93384,,,13100.93384,7771.48,37154,case rate,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,28051.55,19636.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8035.937366,,,8035.937366,6429.37,22441.24,case rate,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17263.03,12084.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7316.909266,,,7316.909266,5687.74,16215.2528,case rate,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,34983.65,24488.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15608.69892,,,15608.69892,7771.48,35233.0168,case rate,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,19683.37,13778.359,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9558.79295,,,9558.79295,6564.403895,21354.2032,case rate,
Nonspecific Cerebrovascular Disorders Without Cc/McC,72,MS-DRG,,,,,,,inpatient,,,12084.89,8459.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6876.12914,,,6876.12914,4030.310815,15200.0264,case rate,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,16388.09,11471.663,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13902.11134,,,13902.11134,5465.428015,31318.012,case rate,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,28055.14,19638.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9457.210356,,,9457.210356,7368.52,22444.112,case rate,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,26116.94,18281.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8348.635091,,,8348.635091,7097.19,20893.552,case rate,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,23235.5,16264.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13908.29463,,,13908.29463,7749.03925,31332.1968,case rate,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,15869.98,11108.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9064.129883,,,9064.129883,5292.63833,20219.4192,case rate,
Hypertensive Encephalopathy Without Cc/McC,79,MS-DRG,,,,,,,inpatient,,,15211.5,10648.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6138.551175,,,6138.551175,5073.03525,13510.0088,case rate,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,53186.54,37230.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17808.18291,,,17808.18291,7771.48,42549.232,case rate,
Nontraumatic Stupor And Coma Without McC,81,MS-DRG,,,,,,,inpatient,,,72271.24,50589.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8241.752535,,,8241.752535,5585.72,57816.992,case rate,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,28572.47,20000.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20744.36155,,,20744.36155,7771.48,47014.5064,case rate,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,30376.08,21263.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12531.18798,,,12531.18798,7771.48,28173.0392,case rate,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,15324.04,10726.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8694.899237,,,8694.899237,5110.56734,19372.384,case rate,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,40898.43,28628.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20265.59836,,,20265.59836,7771.48,45916.1976,case rate,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,13317.55,9322.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11835.12638,,,11835.12638,4441.402925,26578.2624,case rate,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,24255.02,16978.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8058.020539,,,8058.020539,6241.25,19404.016,case rate,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,42230.83,29561.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16351.57685,,,16351.57685,7771.48,36937.2192,case rate,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,30155.68,21108.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9601.192642,,,9601.192642,7134.82,24124.544,case rate,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,16152.97,11307.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7221.50996,,,7221.50996,5387.015495,15994.3752,case rate,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,56481.63,39537.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32479.35948,,,32479.35948,7771.48,73931.1776,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,49973.83,34981.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31913.14693,,,31913.14693,7771.48,72642.3872,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,15617.77,10932.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19411.42125,,,19411.42125,5208.526295,43954.6424,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC,99,MS-DRG,,,,,,,inpatient,,,27081.74,18957.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12556.80447,,,12556.80447,7771.48,28231.8048,case rate,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,34012.87,23809.009,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17786.09974,,,17786.09974,7771.48,40228.0928,case rate,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,18803.33,13162.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8391.034782,,,8391.034782,6270.910555,18675.3024,case rate,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,27377.14,19163.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10491.58616,,,10491.58616,7771.48,23494.0816,case rate,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,23893.76,16725.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7759.456045,,,7759.456045,5992.35,19115.008,case rate,
Acute Major Eye Infections With Cc/McC,121,MS-DRG,,,,,,,inpatient,,,20815.14,14570.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10524.26926,,,10524.26926,6941.84919,23569.0584,case rate,
Acute Major Eye Infections Without Cc/McC,122,MS-DRG,,,,,,,inpatient,,,8234.57,5764.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6241.017096,,,6241.017096,2746.229095,13745.0712,case rate,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,28026.78,19618.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7344.2924,,,7344.2924,5537.24,22421.424,case rate,
Other Disorders Of The Eye With McC Or Thrombolytic Agent,124,MS-DRG,,,,,,,inpatient,,,12298.33,8608.831,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11767.11021,,,11767.11021,4101.493055,26420.2032,case rate,
Other Disorders Of The Eye Without McC,125,MS-DRG,,,,,,,inpatient,,,18740.93,13118.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7543.040953,,,7543.040953,6044.44,16731.9848,case rate,
Mouth Procedures With Cc/McC,137,MS-DRG,,,,,,,inpatient,,,29533.69,20673.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12603.62079,,,12603.62079,7771.48,28339.204,case rate,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,44941.05,31458.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29415.98177,,,29415.98177,7771.48,66905.6488,case rate,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,9316.44,6521.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15766.81444,,,15766.81444,3107.03274,35595.7424,case rate,
Ear- Nose- Mouth And Throat Malignancy With McC,146,MS-DRG,,,,,,,inpatient,,,13156.92,9209.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20513.81322,,,20513.81322,4387.83282,46483.5896,case rate,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,13619.01,9533.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6852.279314,,,6852.279314,4541.939835,15147.34,case rate,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,14296.01,10007.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6945.028639,,,6945.028639,4767.719335,15360.112,case rate,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,12866.36,9006.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10273.40442,,,10273.40442,4290.93106,22993.5608,case rate,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,16420.88,11494.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6536.048282,,,6536.048282,5141.47,14421.8888,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,12009,8406.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14614.95615,,,14614.95615,4005.0015,32953.3168,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,39912.51,27938.757,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8496.150684,,,8496.150684,6561.05,31930.008,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,11067.63,7747.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6188.900808,,,6188.900808,3691.054605,13625.5136,case rate,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,32953.66,23067.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14713.88877,,,14713.88877,7771.48,33180.2736,case rate,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,27223.03,19056.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8557.983567,,,8557.983567,6432.99,21778.424,case rate,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,2839.79,1987.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6075.834964,,,6075.834964,947.069965,13366.1344,case rate,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,115551.53,80886.071,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,40963.7144,,,40963.7144,7771.48,93394.7496,case rate,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,85038.13,59526.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22482.74889,,,22482.74889,7771.48,68030.504,case rate,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,69826.08,48878.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16714.62421,,,16714.62421,7771.48,55860.864,case rate,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,55683.12,38978.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34260.14652,,,34260.14652,7771.48,78036.664,case rate,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,45649.7,31954.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16389.55991,,,16389.55991,7771.48,37024.3544,case rate,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,47015.57,32910.899,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12208.77366,,,12208.77366,7771.48,37612.456,case rate,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,78265.02,54785.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27355.1801,,,27355.1801,7771.48,62612.016,case rate,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,20842.72,14589.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12696.37012,,,12696.37012,6951.04712,28554.0024,case rate,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,18317.47,12822.229,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7444.10834,,,7444.10834,6108.876245,16505.028,case rate,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,31259.62,21881.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14528.39012,,,14528.39012,7771.48,32756.756,case rate,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,20969.38,14678.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9012.896923,,,9012.896923,6993.28823,20103.9144,case rate,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20162.41,14113.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7048.377887,,,7048.377887,6302.75,16129.928,case rate,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,37050.11,25935.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15688.19834,,,15688.19834,7771.48,35415.3928,case rate,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,30930.47,21651.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10056.98932,,,10056.98932,7771.48,24744.376,case rate,
Respiratory Neoplasms Without Cc/McC,182,MS-DRG,,,,,,,inpatient,,,24638.57,17246.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7647.273528,,,7647.273528,5697.87,19710.856,case rate,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,35855.45,25098.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14270.45866,,,14270.45866,7771.48,32163.0208,case rate,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,22588.59,15812.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9684.225371,,,9684.225371,7520.46,21641.952,case rate,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,25741.06,18018.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14205.9758,,,14205.9758,7771.48,32017.12,case rate,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,11443.72,8010.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9118.012825,,,9118.012825,3816.48062,20343.0296,case rate,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,21611.05,15127.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11179.69782,,,11179.69782,7207.285175,25076.7,case rate,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,22710.76,15897.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10169.17184,,,10169.17184,7574.03846,22762.5512,case rate,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,17567.6,12297.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7838.07214,,,7838.07214,5858.7946,17408.8024,case rate,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,13024.23,9116.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5966.302428,,,5966.302428,4343.580705,13114.8608,case rate,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,25981.01,18186.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11889.00933,,,11889.00933,7771.48,26703.8992,case rate,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,18230.9,12761.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7492.69132,,,7492.69132,6080.00515,16616.48,case rate,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,12094.06,8465.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5749.887336,,,5749.887336,4033.36901,12620.4192,case rate,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25422.94,17796.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16892.17291,,,16892.17291,7771.48,38181.4288,case rate,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,23032.67,16122.869,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8994.347058,,,8994.347058,7275.91,20059.3336,case rate,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,22301.78,15611.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15842.78055,,,15842.78055,7437.64363,35770.0128,case rate,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,31940.04,22358.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10032.25617,,,10032.25617,7771.48,25552.032,case rate,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,17352.2,12146.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6230.417173,,,6230.417173,5133.51,13881.76,case rate,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,17596.96,12317.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8788.531889,,,8788.531889,5868.58616,19589.2088,case rate,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,12229.54,8560.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6402.665919,,,6402.665919,4078.55159,14109.8232,case rate,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,30544.64,21381.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7413.191898,,,7413.191898,5734.05,24435.712,case rate,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,23745.99,16622.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16924.85601,,,16924.85601,7771.48,38252.3528,case rate,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,17630.01,12341.007,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8250.585804,,,8250.585804,5879.608335,18355.1312,case rate,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,173078.09,121154.663,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,57375.92829,,,57375.92829,7771.48,138462.472,case rate,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,53859.21,37701.447,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23956.13817,,,23956.13817,7771.48,54390.6024,case rate,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,inpatient,,,221306.62,154914.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,96478.16039,,,96478.16039,7771.48,220737.7784,case rate,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,354301.39,248010.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,93836.12961,,,93836.12961,7771.48,283441.112,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC,216,MS-DRG,,,,,,,inpatient,,,299760.69,209832.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,85500.17361,,,85500.17361,7771.48,239808.552,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,inpatient,,,204620.11,143234.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,57293.77889,,,57293.77889,7771.48,163696.088,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC,219,MS-DRG,,,,,,,inpatient,,,208854.44,146198.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,68596.82996,,,68596.82996,7771.48,167083.552,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,inpatient,,,154365.68,108055.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47036.58687,,,47036.58687,7771.48,123492.544,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,181781.45,127247.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,40817.08213,,,40817.08213,7771.48,145425.16,case rate,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,228758.84,160131.188,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,44268.24035,,,44268.24035,7771.48,183007.072,case rate,
Other Cardiothoracic Procedures Without McC,229,MS-DRG,,,,,,,inpatient,,,95347.28,66743.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27688.19435,,,27688.19435,7771.48,76277.824,case rate,
Coronary Bypass With Ptca With McC,231,MS-DRG,,,,,,,inpatient,,,220697.29,154488.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,75101.64929,,,75101.64929,7771.48,176557.832,case rate,
Coronary Bypass With Ptca Without McC,232,MS-DRG,,,,,,,inpatient,,,203083.55,142158.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,54209.20134,,,54209.20134,7771.48,162466.84,case rate,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,193515.4,135460.78,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,69293.77489,,,69293.77489,7771.48,158379.3712,case rate,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,165546.93,115882.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47244.16869,,,47244.16869,7771.48,132437.544,case rate,
Coronary Bypass Without Cardiac Catheterization With McC,235,MS-DRG,,,,,,,inpatient,,,145342.16,101739.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,52226.13243,,,52226.13243,7771.48,119229.3232,case rate,
Coronary Bypass Without Cardiac Catheterization Without McC,236,MS-DRG,,,,,,,inpatient,,,130227.12,91158.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36572.69635,,,36572.69635,7771.48,104181.696,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,39344.02,27540.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,44741.70357,,,44741.70357,7771.48,102059.636,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,41409.42,28986.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25973.65682,,,25973.65682,7771.48,59008.768,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC,241,MS-DRG,,,,,,,inpatient,,,19499.72,13649.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13586.76364,,,13586.76364,6503.15662,30594.5872,case rate,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,76706.54,53694.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30211.85931,,,30211.85931,7771.48,68735.488,case rate,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,63602.84,44521.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20148.99921,,,20148.99921,7771.48,50882.272,case rate,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,60755.43,42528.801,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16190.81135,,,16190.81135,7771.48,48604.344,case rate,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,109531.23,76671.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43415.82989,,,43415.82989,7771.48,99020.036,case rate,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC,250,MS-DRG,,,,,,,inpatient,,,42609.28,29826.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20677.2287,,,20677.2287,7771.48,46864.5528,case rate,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,52812.94,36969.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14052.27692,,,14052.27692,7771.48,42250.352,case rate,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,100566.7,70396.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30551.05684,,,30551.05684,7771.48,80453.36,case rate,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,72499.37,50749.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22800.74658,,,22800.74658,7771.48,57999.496,case rate,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,68903.94,48232.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15702.33157,,,15702.33157,7771.48,55123.152,case rate,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13134.86,9194.402,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15210.31849,,,15210.31849,4380.47581,34319.1104,case rate,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,20863.13,14604.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8127.803364,,,8127.803364,6957.853855,18073.4616,case rate,
Cardiac Pacemaker Device Replacement With McC,258,MS-DRG,,,,,,,inpatient,,,71596.9,50117.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25031.14702,,,25031.14702,7771.48,57277.52,case rate,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,44827.64,31379.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15775.64771,,,15775.64771,7771.48,35862.112,case rate,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,130030.35,91021.245,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30337.29173,,,30337.29173,7771.48,104024.28,case rate,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,49670.67,34769.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17011.42205,,,17011.42205,7771.48,39736.536,case rate,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC,262,MS-DRG,,,,,,,inpatient,,,58341.51,40839.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13656.54646,,,13656.54646,7771.48,46673.208,case rate,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,49042.27,34329.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31122.56935,,,31122.56935,7771.48,70820.6536,case rate,
Aicd Lead Procedures,265,MS-DRG,,,,,,,inpatient,,,64208.05,44945.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31759.44805,,,31759.44805,7771.48,72279.6616,case rate,
Endovascular Cardiac Valve Replacement And Supplement Procedures With McC,266,MS-DRG,,,,,,,inpatient,,,134751.65,94326.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,53167.75892,,,53167.75892,7771.48,121389.4656,case rate,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC,267,MS-DRG,,,,,,,inpatient,,,133372.27,93360.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41807.29159,,,41807.29159,7771.48,106697.816,case rate,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,241728.99,169210.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,59146.11541,,,59146.11541,7771.48,193383.192,case rate,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,132639.05,92847.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37001.99323,,,37001.99323,7771.48,106111.24,case rate,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,135782.35,95047.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,45590.58073,,,45590.58073,7771.48,108625.88,case rate,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,140000.81,98000.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30674.72261,,,30674.72261,7771.48,112000.648,case rate,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,151532.98,106073.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22352.01651,,,22352.01651,7771.48,121226.384,case rate,
Percutaneous And Other Intracardiac Procedures With McC,273,MS-DRG,,,,,,,inpatient,,,102782.81,71947.967,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34790.14266,,,34790.14266,7771.48,82226.248,case rate,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,82201.95,57541.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27818.0434,,,27818.0434,7771.48,65761.56,case rate,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,183325.52,128327.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,62674.12307,,,62674.12307,7771.48,146660.416,case rate,
Cardiac Defibrillator Implant With McC,276,MS-DRG,,,,,,,inpatient,,,196887.28,137821.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,54966.21249,,,54966.21249,7771.48,157509.824,case rate,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,177791.04,124453.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41340.89499,,,41340.89499,7771.48,142232.832,case rate,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,157626.97,110338.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,44444.90573,,,44444.90573,7771.48,126101.576,case rate,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,93744.91,65621.437,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28554.73804,,,28554.73804,7771.48,74995.928,case rate,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31041.23,21728.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14748.33852,,,14748.33852,7771.48,33263.356,case rate,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,26543.44,18580.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8391.918109,,,8391.918109,6744.11,21234.752,case rate,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,23815.3,16670.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6654.414087,,,6654.414087,5249.28,19052.24,case rate,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,19212.47,13448.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17521.985,,,17521.985,6407.358745,39624.2256,case rate,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,10954.07,7667.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6794.863065,,,6794.863065,3653.182345,15013.5976,case rate,
Acute Myocardial Infarction- Expired Without Cc/McC,285,MS-DRG,,,,,,,inpatient,,,7163.26,5014.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5208.407944,,,5208.407944,2388.94721,11374.1832,case rate,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,38892.53,27224.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19800.08508,,,19800.08508,7771.48,44850.3112,case rate,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,30727.74,21509.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9875.023982,,,9875.023982,7771.48,24582.192,case rate,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,28457.96,19920.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,24377.48511,,,24377.48511,7771.48,55347.0632,case rate,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,19767.12,13836.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14176.82601,,,14176.82601,6592.33452,31948.2224,case rate,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,20727.01,14508.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11775.06015,,,11775.06015,6912.457835,26442.4936,case rate,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,15225.15,10657.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7856.622005,,,7856.622005,5077.587525,17453.3832,case rate,
Heart Failure And Shock Without Cc/McC,293,MS-DRG,,,,,,,inpatient,,,10124.22,7086.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5096.225427,,,5096.225427,3376.42737,11124.936,case rate,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,25950.27,18165.189,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14721.83871,,,14721.83871,7771.48,33198.5112,case rate,
Cardiac Arrest- Unexplained With Cc,297,MS-DRG,,,,,,,inpatient,,,10642.36,7449.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6471.565418,,,6471.565418,3549.22706,14273.9616,case rate,
Cardiac Arrest- Unexplained Without Cc/McC,298,MS-DRG,,,,,,,inpatient,,,12953.57,9067.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4151.065639,,,4151.065639,4151.065639,10362.856,case rate,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,22073.95,15451.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14538.10671,,,14538.10671,7361.662325,32781.0728,case rate,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,21942.88,15360.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9706.308543,,,9706.308543,7317.95048,21692.612,case rate,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,24649.73,17254.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6551.064839,,,6551.064839,5372.28,19719.784,case rate,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,9953.04,6967.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10525.15258,,,10525.15258,3319.33884,23571.0848,case rate,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16791.27,11753.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6188.900808,,,6188.900808,4894.02,13625.5136,case rate,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,37676.15,26373.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10626.73518,,,10626.73518,7771.48,30140.92,case rate,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,16488.7,11542.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6880.545775,,,6880.545775,5343.34,15212.1848,case rate,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,22172.6,15520.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13476.34777,,,13476.34777,7394.5621,30343.3136,case rate,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,15582.95,10908.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8432.551146,,,8432.551146,5196.913825,18770.5432,case rate,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,19410.63,13587.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10901.44985,,,10901.44985,6473.445105,24438.384,case rate,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,14290.45,10003.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6779.846508,,,6779.846508,4765.865075,14981.1752,case rate,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,11407.4,7985.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5191.624733,,,5191.624733,3804.3679,11337.708,case rate,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,11897.35,8328.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6417.682477,,,6417.682477,3967.766225,14154.404,case rate,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,16541.17,11578.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7945.838022,,,7945.838022,5516.480195,17656.0232,case rate,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,15084.64,10559.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6551.064839,,,6551.064839,5030.72744,14454.3112,case rate,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,31164.15,21814.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19271.8556,,,19271.8556,7771.48,43636.4976,case rate,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,18201.8,12741.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8749.665505,,,8749.665505,6070.3003,19500.0472,case rate,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,10045.09,7031.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6279.883479,,,6279.883479,3350.037515,13832.2064,case rate,
Other Endovascular Cardiac Valve Procedures With McC,319,MS-DRG,,,,,,,inpatient,,,92577.92,64804.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39052.19498,,,39052.19498,7771.48,89009.62,case rate,
Other Endovascular Cardiac Valve Procedures Without McC,320,MS-DRG,,,,,,,inpatient,,,39673.91,27771.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20696.66189,,,20696.66189,7771.48,46903.0544,case rate,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,92249.33,64574.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25395.96103,,,25395.96103,7771.48,73799.464,case rate,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,75877.65,53114.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16230.56106,,,16230.56106,7771.48,60702.12,case rate,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,116736.51,81715.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37873.83688,,,37873.83688,7771.48,93389.208,case rate,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,126333.04,88433.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28472.58864,,,28472.58864,7771.48,101066.432,case rate,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,inpatient,,,98701.5,69091.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25531.11004,,,25531.11004,7771.48,78961.2,case rate,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,64991.97,45494.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,45113.5842,,,45113.5842,7771.48,102914.7768,case rate,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,59110.49,41377.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21697.47128,,,21697.47128,7771.48,49203.0184,case rate,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,49561.22,34692.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14325.22493,,,14325.22493,7771.48,39648.976,case rate,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,78913.19,55239.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,40810.89884,,,40810.89884,7771.48,93046.2088,case rate,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,69586.46,48710.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21128.60875,,,21128.60875,7771.48,55669.168,case rate,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,57546.85,40282.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14833.1379,,,14833.1379,7771.48,46037.48,case rate,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,97325,68127.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19022.75741,,,19022.75741,7771.48,77860,case rate,
Rectal Resection Without Cc/McC,334,MS-DRG,,,,,,,inpatient,,,106215.45,74350.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14900.27074,,,14900.27074,7771.48,84972.36,case rate,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,73034.84,51124.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32255.87777,,,32255.87777,7771.48,73434.7096,case rate,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,43630.89,30541.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18907.92491,,,18907.92491,7771.48,42805.6736,case rate,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,37370.19,26159.133,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13809.36202,,,13809.36202,7771.48,31105.24,case rate,
Minor Small And Large Bowel Procedures With McC,344,MS-DRG,,,,,,,inpatient,,,23852.76,16696.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,24050.65415,,,24050.65415,7771.48,54599.3216,case rate,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,15908.61,11136.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13399.49833,,,13399.49833,5305.521435,30177.1488,case rate,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,21216.99,14851.893,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11249.48065,,,11249.48065,7075.866165,25232.7328,case rate,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,44922.74,31445.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21155.99188,,,21155.99188,7771.48,47956.7824,case rate,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,23475.59,16432.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11369.61311,,,11369.61311,7771.48,25508.3232,case rate,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,34354.1,24047.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13539.06398,,,13539.06398,7771.48,30491.2408,case rate,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,42230.08,29561.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9988.973153,,,9988.973153,7771.48,33784.064,case rate,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,312395.2,218676.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26157.38882,,,26157.38882,7771.48,249916.16,case rate,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,44235.04,30964.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15275.68468,,,15275.68468,7771.48,35388.032,case rate,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,51507.45,36055.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12025.925,,,12025.925,7771.48,41205.96,case rate,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,70735.47,49514.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37929.48648,,,37929.48648,7771.48,86434.0656,case rate,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,77577.93,54304.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20141.9326,,,20141.9326,7771.48,62062.344,case rate,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,27080.24,18956.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12219.37359,,,12219.37359,7771.48,27457.72,case rate,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,23431.55,16402.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15000.97001,,,15000.97001,7771.48,33838.8536,case rate,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,31489.94,22042.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9238.145284,,,9238.145284,7771.48,25191.952,case rate,
Major Esophageal Disorders Without Cc/McC,370,MS-DRG,,,,,,,inpatient,,,29793.71,20855.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6415.032496,,,6415.032496,5409.18,23834.968,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,37215.27,26050.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15689.965,,,15689.965,7771.48,35427.5512,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,24764.87,17335.409,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9341.494532,,,9341.494532,7435.09,20857.7352,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,19807.89,13865.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6657.064068,,,6657.064068,5379.51,15846.312,case rate,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,38795.7,27156.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18899.97497,,,18899.97497,7771.48,42787.436,case rate,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,40108.1,28075.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11102.84838,,,11102.84838,7771.48,32086.48,case rate,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,8031.54,5622.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8049.18727,,,8049.18727,2678.51859,17891.0856,case rate,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,38252.31,26776.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16310.06048,,,16310.06048,7771.48,36841.9784,case rate,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,30659.48,21461.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8958.130655,,,8958.130655,7186.19,24527.584,case rate,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,17080.5,11956.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5873.553103,,,5873.553103,4609.67,13664.4,case rate,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33361.1,23352.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17247.27033,,,17247.27033,7771.48,38994.0152,case rate,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,34876.59,24413.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9869.724021,,,9869.724021,7667.34,27901.272,case rate,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,23295.58,16306.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7930.821465,,,7930.821465,6456.86,18636.464,case rate,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,19010.83,13307.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14601.70625,,,14601.70625,6340.111805,32922.9208,case rate,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,17687.57,12381.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9016.430231,,,9016.430231,5898.804595,20109.9936,case rate,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12268.03,8587.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6170.350943,,,6170.350943,4091.388005,13582.9592,case rate,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,35037.99,24526.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13233.43287,,,13233.43287,7771.48,29788.08,case rate,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,19193.48,13435.436,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7330.159169,,,7330.159169,5946.04,16245.6488,case rate,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12403.72,8682.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5082.975523,,,5082.975523,4136.64062,11086.4344,case rate,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,23697.98,16588.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11595.74479,,,11595.74479,7771.48,26037.2136,case rate,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16680.62,11676.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7142.010538,,,7142.010538,5530.73,15811.9992,case rate,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,35226.46,24658.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14877.30424,,,14877.30424,7771.48,33555.1576,case rate,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,21027.93,14719.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8564.166855,,,8564.166855,6791.14,19074.5032,case rate,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,19292.51,13504.757,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5870.903122,,,5870.903122,4700.83,15434.008,case rate,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,31379.86,21965.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22136.48475,,,22136.48475,7771.48,50206.0864,case rate,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,37379.45,26165.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13615.91342,,,13615.91342,7771.48,30665.5112,case rate,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,31865.55,22305.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10176.23846,,,10176.23846,7771.48,25492.44,case rate,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,43167.44,30217.208,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25056.7635,,,25056.7635,7771.48,56905.3648,case rate,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,37981.98,26587.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19115.50673,,,19115.50673,7771.48,43275.7984,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC,408,MS-DRG,,,,,,,inpatient,,,66496.81,46547.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31177.33562,,,31177.33562,7771.48,70946.2904,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,54723.42,38306.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18768.35926,,,18768.35926,7771.48,43778.736,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC,410,MS-DRG,,,,,,,inpatient,,,49332.9,34533.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13950.69432,,,13950.69432,7771.48,39466.32,case rate,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,inpatient,,,94854.82,66398.374,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19078.407,,,19078.407,7771.48,75883.856,case rate,
Cholecystectomy Except By Laparoscope Without C.D.E. With McC,414,MS-DRG,,,,,,,inpatient,,,158479.92,110935.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31199.41879,,,31199.41879,7771.48,126783.936,case rate,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/McC,416,MS-DRG,,,,,,,inpatient,,,36054.28,25237.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12352.75595,,,12352.75595,7771.48,28843.424,case rate,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,57775.9,40443.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21241.67459,,,21241.67459,7771.48,48157.396,case rate,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,45650.74,31955.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14898.50409,,,14898.50409,7771.48,36520.592,case rate,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,40583.9,28408.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11888.126,,,11888.126,7771.48,32467.12,case rate,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,43141.15,30198.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31426.43381,,,31426.43381,7771.48,71515.7088,case rate,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,126455.95,88519.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36177.84923,,,36177.84923,7771.48,101164.76,case rate,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,inpatient,,,66431.87,46502.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20418.41392,,,20418.41392,7771.48,53145.496,case rate,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,37750.2,26425.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17554.66809,,,17554.66809,7771.48,39699.2024,case rate,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,22206.74,15544.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9699.241928,,,9699.241928,7405.94779,21676.4008,case rate,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,9888.24,6921.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6401.782592,,,6401.782592,3297.72804,14111.8496,case rate,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41222.48,28855.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16366.59341,,,16366.59341,7771.48,36971.668,case rate,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,21857.06,15299.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10210.68821,,,10210.68821,7289.32951,22849.6864,case rate,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,34142.65,23899.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14945.32042,,,14945.32042,7771.48,33715.2432,case rate,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,18774.77,13142.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7847.788735,,,7847.788735,6109.56,17431.0928,case rate,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,12926.06,9048.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5682.754492,,,5682.754492,4310.84101,12464.3864,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,33617.1,23531.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16947.82251,,,16947.82251,7771.48,38305.0392,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,18826.25,13178.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8784.115255,,,8784.115255,6278.554375,19579.0768,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,9263.58,6484.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6456.54886,,,6456.54886,3089.40393,14237.4864,case rate,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,36248.92,25374.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15128.16909,,,15128.16909,7771.48,34134.708,case rate,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,33226.4,23258.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9829.090983,,,9829.090983,7771.48,26581.12,case rate,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,28308.58,19816.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7292.176112,,,7292.176112,5905.53,22646.864,case rate,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With McC,456,MS-DRG,,,,,,,inpatient,,,202351.8,141646.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,75060.13292,,,75060.13292,7771.48,171607.7104,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,70294.35,49206.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47957.89683,,,47957.89683,7771.48,109439.7848,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,25826.71,18078.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26295.18782,,,26295.18782,7771.48,59750.4304,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,10589.98,7412.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15584.84909,,,15584.84909,3531.75833,35176.2776,case rate,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,134518.68,94163.076,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,45251.38319,,,45251.38319,7771.48,107614.944,case rate,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,95919.47,67143.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30505.12384,,,30505.12384,7771.48,76735.576,case rate,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,68797.87,48158.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23421.72539,,,23421.72539,7771.48,55038.296,case rate,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,54280.26,37996.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29122.71724,,,29122.71724,7771.48,66232.884,case rate,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,53419.21,37393.447,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16904.53949,,,16904.53949,7771.48,42735.368,case rate,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68987.67,48291.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43155.24845,,,43155.24845,7771.48,98422.248,case rate,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,77778.52,54444.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25841.15779,,,25841.15779,7771.48,62222.816,case rate,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,54869.65,38408.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21161.29185,,,21161.29185,7771.48,47968.9408,case rate,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,71787.88,50251.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39863.9724,,,39863.9724,7771.48,90871.8816,case rate,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,33747.79,23623.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19305.42202,,,19305.42202,7771.48,43711.4744,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,89768.8,62838.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30627.02296,,,30627.02296,7771.48,71815.04,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,65676.03,45973.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20906.8937,,,20906.8937,7771.48,52540.824,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,26493.14,18545.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15935.52988,,,15935.52988,7771.48,35982.7848,case rate,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,50028.86,35020.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26228.05497,,,26228.05497,7771.48,59596.424,case rate,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,54052.44,37836.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18577.56065,,,18577.56065,7771.48,43241.952,case rate,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,42724.18,29906.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14262.50872,,,14262.50872,7771.48,34179.344,case rate,
Knee Procedures With Principal Diagnosis Of Infection With McC,485,MS-DRG,,,,,,,inpatient,,,78688.59,55082.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28686.35375,,,28686.35375,7771.48,65323.0304,case rate,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,38633.42,27043.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18983.89102,,,18983.89102,7771.48,42973.8648,case rate,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,68635.57,48044.899,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17610.31769,,,17610.31769,7771.48,54908.456,case rate,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,35436.81,24805.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11188.53109,,,11188.53109,7771.48,28349.448,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,77413.36,54189.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31618.11574,,,31618.11574,7771.48,71957.464,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,79988.8,55992.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21458.08969,,,21458.08969,7771.48,63991.04,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,52007.74,36405.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16903.65616,,,16903.65616,7771.48,41606.192,case rate,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC,495,MS-DRG,,,,,,,inpatient,,,55215.82,38651.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31347.81771,,,31347.81771,7771.48,71335.3592,case rate,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC,499,MS-DRG,,,,,,,inpatient,,,24343.66,17040.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10503.06941,,,10503.06941,7771.48,23522.4512,case rate,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,43692.12,30584.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28239.39033,,,28239.39033,7771.48,64206.484,case rate,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,30673.94,21471.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16014.14597,,,16014.14597,7771.48,36169.2136,case rate,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,41306.96,28914.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23627.54056,,,23627.54056,7771.48,53628.676,case rate,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,37180.29,26026.203,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15751.79788,,,15751.79788,7771.48,35575.4784,case rate,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,63266.34,44286.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17370.05277,,,17370.05277,7771.48,50613.072,case rate,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,57782.59,40447.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25495.77697,,,25495.77697,7771.48,57914.512,case rate,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,39749.27,27824.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17573.21796,,,17573.21796,7771.48,39745.8096,case rate,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,26213.06,18349.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13548.78058,,,13548.78058,7771.48,30507.452,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,64680.35,45276.245,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27565.41191,,,27565.41191,7771.48,62660.3408,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,33187.16,23231.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18019.29804,,,18019.29804,7771.48,40763.0624,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,28664.41,20065.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13434.83141,,,13434.83141,7771.48,30246.0464,case rate,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,52006.98,36404.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31907.84697,,,31907.84697,7771.48,72622.1232,case rate,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,60945.78,42662.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17667.73394,,,17667.73394,7771.48,48756.624,case rate,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,27733.63,19413.541,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12909.2519,,,12909.2519,7771.48,29040.3384,case rate,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,64155.47,44908.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25995.74,,,25995.74,7771.48,59061.4544,case rate,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59467.45,41627.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18870.82518,,,18870.82518,7771.48,47573.96,case rate,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,24348.24,17043.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11996.77521,,,11996.77521,7771.48,26949.0936,case rate,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,14748.61,10324.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7412.308571,,,7412.308571,4918.661435,16432.0776,case rate,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,34525.72,24168.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18113.81402,,,18113.81402,7771.48,40987.9928,case rate,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,27528.18,19269.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11680.54418,,,11680.54418,7771.48,26229.7216,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,28046.03,19632.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16724.3408,,,16724.3408,7771.48,37790.3336,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,29133.49,20393.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9620.625833,,,9620.625833,7548.68,23306.792,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,17251.52,12076.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6924.71212,,,6924.71212,5616.11,15313.5048,case rate,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,10607.77,7425.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22570.19826,,,22570.19826,3537.691295,51201.0488,case rate,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,22929.4,16050.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10475.68628,,,10475.68628,7646.9549,23459.6328,case rate,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,15898.64,11129.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6840.796064,,,6840.796064,5302.19644,15120.9968,case rate,
Septic Arthritis Without Cc/McC,550,MS-DRG,,,,,,,inpatient,,,13751.03,9625.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7864.571947,,,7864.571947,4585.968505,17469.5944,case rate,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,34050.51,23835.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15322.501,,,15322.501,7771.48,34576.4632,case rate,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,21070.26,14749.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8762.915409,,,8762.915409,6815.74,19530.4432,case rate,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,37105.01,25973.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11785.66008,,,11785.66008,7771.48,29684.008,case rate,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,33214.93,23250.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7621.657048,,,7621.657048,5718.85,26571.944,case rate,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC,555,MS-DRG,,,,,,,inpatient,,,16910.44,11837.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12144.2908,,,12144.2908,5639.63174,27285.476,case rate,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,38978.42,27284.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7461.774878,,,7461.774878,5833.89,31182.736,case rate,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,25775.81,18043.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13938.32774,,,13938.32774,7771.48,31403.1208,case rate,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,17322.32,12125.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7879.588504,,,7879.588504,5776.99372,17504.0432,case rate,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,46066.43,32246.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16646.60803,,,16646.60803,7771.48,37612.0104,case rate,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,43659.99,30561.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10307.85417,,,10307.85417,7771.48,34927.992,case rate,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,35419.71,24793.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7471.491474,,,7471.491474,5723.92,28335.768,case rate,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,23360.4,16352.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13176.89995,,,13176.89995,7771.48,29660.4168,case rate,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,23376.03,16363.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8144.586575,,,8144.586575,6300.58,18700.824,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,24152.97,16907.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14110.57649,,,14110.57649,7771.48,31798.2688,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,26103.05,18272.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9256.695149,,,9256.695149,7280.97,20882.44,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,12203.73,8542.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6857.579275,,,6857.579275,4069.943955,15157.472,case rate,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,58121.61,40685.127,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26839.31719,,,26839.31719,7771.48,61002.7456,case rate,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,22908.56,16035.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15038.95307,,,15038.95307,7640.00476,33938.1472,case rate,
Skin Debridement Without Cc/McC,572,MS-DRG,,,,,,,inpatient,,,34042.21,23829.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10340.53726,,,10340.53726,7771.48,27233.768,case rate,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,40320.12,28224.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,54646.44815,,,54646.44815,7771.48,124781.6592,case rate,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,31675.49,22172.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30855.80463,,,30855.80463,7771.48,70208.6808,case rate,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC,575,MS-DRG,,,,,,,inpatient,,,33248.67,23274.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17886.79901,,,17886.79901,7771.48,40457.076,case rate,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,inpatient,,,22694.73,15886.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23770.63952,,,23770.63952,7568.692455,53954.9264,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,47774,33441.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29040.56784,,,29040.56784,7771.48,66042.4024,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,21385.31,14969.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15910.79672,,,15910.79672,7132.000885,35926.0456,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,107178.51,75024.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12962.25151,,,12962.25151,7771.48,85742.808,case rate,
Breast Biopsy- Local Excision And Other Breast Procedures Without Cc/McC,585,MS-DRG,,,,,,,inpatient,,,37278.64,26095.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17784.33309,,,17784.33309,7771.48,40224.04,case rate,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,53897.07,37727.949,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18413.26184,,,18413.26184,7771.48,43117.656,case rate,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,22540.18,15778.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7746.206141,,,7746.206141,5923.61,18032.144,case rate,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,26958.01,18870.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9799.057868,,,9799.057868,7157.25,21905.384,case rate,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,36927.76,25849.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15766.81444,,,15766.81444,7771.48,35593.716,case rate,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,9105.56,6373.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9779.624676,,,9779.624676,3036.70426,21862.8296,case rate,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,5148.62,3604.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5544.955495,,,5544.955495,1717.06477,12148.268,case rate,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,21201.17,14840.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13227.24959,,,13227.24959,7070.590195,29775.9216,case rate,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,14711.96,10298.372,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8029.754078,,,8029.754078,4906.43866,17850.5576,case rate,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,29329.16,20530.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13372.99853,,,13372.99853,7771.48,30106.2248,case rate,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21984.9,15389.43,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8408.70132,,,8408.70132,6578.42,18717.8568,case rate,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,26207.89,18345.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14473.62385,,,14473.62385,7771.48,32627.0664,case rate,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,18364.58,12855.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7883.121812,,,7883.121812,5973.54,17514.1752,case rate,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,63303.79,44312.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34389.99557,,,34389.99557,7771.48,78318.3336,case rate,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,33293.26,23305.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17311.75319,,,17311.75319,7771.48,39154.1008,case rate,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,inpatient,,,47713.27,33399.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14356.14137,,,14356.14137,7771.48,38170.616,case rate,
O.R. Procedures For Obesity Without Cc/McC,621,MS-DRG,,,,,,,inpatient,,,43994.97,30796.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13161.88339,,,13161.88339,7771.48,35195.976,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,12496.79,8747.753,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,33303.50348,,,33303.50348,7771.48,75868.416,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,19840.3,13888.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17145.68774,,,17145.68774,6616.74005,38785.296,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,624,MS-DRG,,,,,,,inpatient,,,15962.42,11173.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9110.062882,,,9110.062882,5323.46707,20326.8184,case rate,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,76735.34,53714.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35102.84038,,,35102.84038,7771.48,79967.8232,case rate,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,36824.85,25777.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20116.31612,,,20116.31612,7771.48,45596.0264,case rate,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,27285.79,19100.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13113.30042,,,13113.30042,7771.48,29510.4632,case rate,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,17323.96,12126.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8351.285071,,,8351.285071,5777.54066,18586.1408,case rate,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,11395.93,7977.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5784.337086,,,5784.337086,3800.542655,12697.4224,case rate,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,21542.6,15079.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11979.992,,,11979.992,7184.4571,26912.6184,case rate,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,14225.97,9958.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7151.727134,,,7151.727134,4744.360995,15836.316,case rate,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,13622.93,9536.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11212.38092,,,11212.38092,4543.247155,25149.6504,case rate,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,60349.49,42244.643,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14888.78749,,,14888.78749,7771.48,48279.592,case rate,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,13236.15,9265.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9377.710935,,,9377.710935,4414.256025,20942.844,case rate,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13028.88,9120.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7127.877308,,,7127.877308,4345.13148,15785.656,case rate,
Major Bladder Procedures Without Cc/McC,655,MS-DRG,,,,,,,inpatient,,,55359.22,38751.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18598.76049,,,18598.76049,7771.48,44287.376,case rate,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,47307.79,33115.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29028.20126,,,29028.20126,7771.48,66014.0328,case rate,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,42988.03,30091.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16397.50985,,,16397.50985,7771.48,37042.592,case rate,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,30491.37,21343.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23077.2279,,,23077.2279,7771.48,52366.2288,case rate,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,26889.16,18822.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12085.99122,,,12085.99122,7771.48,27151.7336,case rate,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,19523.55,13666.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9317.644705,,,9317.644705,6511.103925,20803.0224,case rate,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,57156.94,40009.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27805.67682,,,27805.67682,7771.48,63211.5216,case rate,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,29787.18,20851.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13741.34584,,,13741.34584,7771.48,30949.2072,case rate,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,15013.42,10509.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9787.574618,,,9787.574618,5006.97557,21881.0672,case rate,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,28865.76,20206.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30579.3233,,,30579.3233,7771.48,69574.4176,case rate,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,28047.28,19633.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14800.4548,,,14800.4548,7771.48,33378.8608,case rate,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,51984.11,36388.877,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26009.87323,,,26009.87323,7771.48,59091.8504,case rate,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,30494.67,21346.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13918.89455,,,13918.89455,7771.48,31358.54,case rate,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,12447.8,8713.46,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8691.36593,,,8691.36593,4151.3413,19364.2784,case rate,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,72572.36,50800.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37257.27471,,,37257.27471,7771.48,84906.16,case rate,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,49815.27,34870.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20640.12897,,,20640.12897,7771.48,46775.3912,case rate,
Other Kidney And Urinary Tract Procedures Without Cc/McC,675,MS-DRG,,,,,,,inpatient,,,67065.03,46945.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14076.12674,,,14076.12674,7771.48,53652.024,case rate,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25198.22,17638.754,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13516.09748,,,13516.09748,7771.48,30436.528,case rate,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,16815.75,11771.025,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8101.303557,,,8101.303557,5608.052625,18012.6696,case rate,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,11199.54,7839.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5614.73832,,,5614.73832,3735.04659,12310.38,case rate,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,17030.3,11921.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16906.30614,,,16906.30614,5679.60505,38209.7984,case rate,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,10555.37,7388.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9548.193027,,,9548.193027,3520.215895,21329.8864,case rate,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,21612.22,15128.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10586.98547,,,10586.98547,7207.67537,23716.9856,case rate,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,14540.91,10178.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7338.992438,,,7338.992438,4849.393485,16263.8864,case rate,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,27273.94,19091.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13237.84951,,,13237.84951,7771.48,29794.1592,case rate,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,11406.89,7984.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7151.727134,,,7151.727134,3804.197815,15834.2896,case rate,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,22314.56,15620.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10211.57153,,,10211.57153,7441.90576,22851.7128,case rate,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,14767.92,10337.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6360.266228,,,6360.266228,4925.10132,14016.6088,case rate,
Urethral Stricture,697,MS-DRG,,,,,,,inpatient,,,14675.76,10273.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9098.579633,,,9098.579633,4894.36596,20300.4752,case rate,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,24798.67,17359.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15097.25264,,,15097.25264,7771.48,34061.7576,case rate,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,17120.52,11984.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9258.461802,,,9258.461802,5709.69342,20665.2272,case rate,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,41107.29,28775.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6381.466073,,,6381.466073,5388.92,32885.832,case rate,
Major Male Pelvic Procedures With Cc/McC,707,MS-DRG,,,,,,,inpatient,,,35017.36,24512.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17391.25262,,,17391.25262,7771.48,39322.292,case rate,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,31613.04,22129.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13344.73206,,,13344.73206,7771.48,30039.3536,case rate,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,20964.14,14674.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20098.64958,,,20098.64958,6991.54069,45533.208,case rate,
Penis Procedures Without Cc/McC,710,MS-DRG,,,,,,,inpatient,,,68393.44,47875.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13511.68085,,,13511.68085,7771.48,54714.752,case rate,
Testes Procedures With Cc/McC,711,MS-DRG,,,,,,,inpatient,,,36907.35,25835.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17126.25454,,,17126.25454,7771.48,38716.3984,case rate,
Testes Procedures Without Cc/McC,712,MS-DRG,,,,,,,inpatient,,,18463.04,12924.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9697.475274,,,9697.475274,6157.42384,21674.3744,case rate,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,14941.94,10459.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13022.31774,,,13022.31774,4983.13699,29299.7176,case rate,
Transurethral Prostatectomy Without Cc/McC,714,MS-DRG,,,,,,,inpatient,,,10164.77,7115.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8550.033625,,,8550.033625,3389.950795,19040.0544,case rate,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC,715,MS-DRG,,,,,,,inpatient,,,36701.12,25690.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20197.58219,,,20197.58219,7771.48,45760.1648,case rate,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,23580.89,16506.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16639.54142,,,16639.54142,7771.48,37597.8256,case rate,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC,718,MS-DRG,,,,,,,inpatient,,,27747.61,19423.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11131.11484,,,11131.11484,7771.48,24961.1952,case rate,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,48176.72,33723.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10168.28851,,,10168.28851,7771.48,38541.376,case rate,
Benign Prostatic Hypertrophy With McC,725,MS-DRG,,,,,,,inpatient,,,31783.16,22248.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11402.2962,,,11402.2962,7771.48,25595.4584,case rate,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,10731.22,7511.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6824.89618,,,6824.89618,3578.86187,15082.4952,case rate,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,9268.85,6488.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7467.074839,,,7467.074839,3091.161475,16557.7144,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC,739,MS-DRG,,,,,,,inpatient,,,70791.15,49553.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35413.77145,,,35413.77145,7771.48,80664.9048,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,inpatient,,,61565.64,43095.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16310.94381,,,16310.94381,7771.48,49252.512,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC,741,MS-DRG,,,,,,,inpatient,,,66917.01,46841.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12382.78906,,,12382.78906,7771.48,53533.608,case rate,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,24878.38,17414.866,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16385.14327,,,16385.14327,7771.48,37014.2224,case rate,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,27909.66,19536.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10837.85031,,,10837.85031,7771.48,24288.4304,case rate,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,16030.6,11221.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8686.949295,,,8686.949295,5346.2051,19354.1464,case rate,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,22664.36,15865.052,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10055.22267,,,10055.22267,7558.56406,22495.0664,case rate,
Infections- Female Reproductive System With McC,757,MS-DRG,,,,,,,inpatient,,,15549.35,10884.545,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12751.13638,,,12751.13638,5185.708225,28677.6128,case rate,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,10151.59,7106.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9253.161841,,,9253.161841,3385.555265,20655.0952,case rate,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,10881.96,7617.372,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8955.480674,,,8955.480674,3629.13366,19970.172,case rate,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14849.95,10394.965,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9933.323558,,,9933.323558,4952.458325,13906.65298,case rate,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,25190.93,17633.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12523.23804,,,12523.23804,7771.48,28156.828,case rate,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,6415.51,4490.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9754.008196,,,9754.008196,2139.572585,21802.0376,case rate,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,10227.7,7159.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6551.948166,,,6551.948166,3410.93795,14456.3376,case rate,
Abortion Without D&C,779,MS-DRG,,,,,,,inpatient,,,13854.84,9698.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8506.750606,,,8506.750606,4620.58914,18940.7608,case rate,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,19969.28,13978.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16521.17561,,,16521.17561,6659.75488,23129.64586,case rate,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,17660.24,12362.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9815.841079,,,9815.841079,5889.69004,14128.192,case rate,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,16297.53,11408.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7965.271214,,,7965.271214,5435.226255,13038.024,case rate,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,19789.47,13852.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14523.09016,,,14523.09016,6599.788245,20332.32622,case rate,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,17268.46,12087.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9628.575776,,,9628.575776,5759.03141,13814.768,case rate,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,16414.17,11489.919,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8240.869208,,,8240.869208,5474.125695,13131.336,case rate,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,4752.37,3326.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16172.26149,,,16172.26149,1584.915395,22641.16608,case rate,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,54759.69,38331.783,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,52761.42854,,,52761.42854,2909,73865.99995,case rate,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39693.75,27785.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36111.59971,,,36111.59971,2909,50556.23959,case rate,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,7967.7,5577.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21888.26989,,,21888.26989,2657.22795,30643.57784,case rate,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,10068.5,7047.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37088.55927,,,37088.55927,2909,51923.98297,case rate,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5320.51,3724.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13289.08247,,,13289.08247,1774.390085,18604.71546,case rate,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4248.78,2974.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2014.297856,,,2014.297856,1378.34,7947.23,case rate,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,9202.02,6441.414,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8801.781793,,,8801.781793,3068.87367,12322.49451,case rate,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,inpatient,,,55562.6,38893.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25987.79005,,,25987.79005,7771.48,59041.1904,case rate,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,36233.96,25363.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10015.47296,,,10015.47296,7771.48,28987.168,case rate,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,14129.33,9890.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9065.01321,,,9065.01321,4712.131555,12691.01849,case rate,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13166.38,9216.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6641.164183,,,6641.164183,4390.98773,10533.104,case rate,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,12520.32,8764.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5878.853065,,,5878.853065,4175.52672,10016.256,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,50163.84,35114.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20480.2468,,,20480.2468,7771.48,46412.6656,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,18648.29,13053.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11189.41442,,,11189.41442,6219.204715,25096.964,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,10877.8,7614.46,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8656.91618,,,8656.91618,3627.7463,19285.2488,case rate,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,32327.52,22629.264,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12676.93692,,,12676.93692,7771.48,28507.3952,case rate,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,22300.24,15610.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8401.634705,,,8401.634705,6364.97,18701.6456,case rate,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,33797.91,23658.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13923.31119,,,13923.31119,7771.48,31366.6456,case rate,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,19042.28,13329.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18715.35965,,,18715.35965,6350.60038,42357.8392,case rate,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,19035.73,13325.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9224.89538,,,9224.89538,6348.415955,20590.2504,case rate,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,34218.62,23953.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22642.63106,,,22642.63106,7771.48,51371.2664,case rate,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,53653,37557.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19968.80052,,,19968.80052,7771.48,45233.3008,case rate,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,70337.4,49236.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41584.69321,,,41584.69321,7771.48,94819.3088,case rate,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,inpatient,,,93776.03,65643.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19677.30265,,,19677.30265,7771.48,75020.824,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,73575.27,51502.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,42432.68704,,,42432.68704,7771.48,96764.6528,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,inpatient,,,54189.56,37932.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21095.04233,,,21095.04233,7771.48,47816.9608,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,45890.81,32123.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14408.25766,,,14408.25766,7771.48,36712.648,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,19580.15,13706.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27489.44579,,,27489.44579,6529.980025,62486.0704,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC,830,MS-DRG,,,,,,,inpatient,,,39587.15,27711.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13168.06668,,,13168.06668,7771.48,31669.72,case rate,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,19450.76,13615.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10416.50337,,,10416.50337,6486.82846,23321.8376,case rate,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,17150.01,12005.007,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6851.395987,,,6851.395987,5642.16,15143.2872,case rate,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,11361.65,7953.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4840.943951,,,4840.943951,3789.110275,10533.2272,case rate,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,9828.38,6879.866,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,49073.53871,,,49073.53871,3277.76473,111997.1016,case rate,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,18619.01,13033.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19116.39006,,,19116.39006,6209.439835,43279.8512,case rate,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,24808.35,17365.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28418.7057,,,28418.7057,7771.48,64630.0016,case rate,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,16962.7,11873.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14099.97657,,,14099.97657,5657.06045,31771.9256,case rate,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,31741.3,22218.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9541.126412,,,9541.126412,7771.48,25393.04,case rate,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,19222.18,13455.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16973.43899,,,16973.43899,6410.59703,38361.7784,case rate,
Radiotherapy,849,MS-DRG,,,,,,,inpatient,,,58144.26,40700.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23843.95566,,,23843.95566,7771.48,54123.1176,case rate,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,85769.92,60038.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,44427.23919,,,44427.23919,7771.48,101350.396,case rate,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,33994.9,23796.43,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17899.16559,,,17899.16559,7771.48,40491.5248,case rate,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65980.01,46186.007,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,40101.58734,,,40101.58734,7771.48,91416.9832,case rate,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,32658.71,22861.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19496.22063,,,19496.22063,7771.48,44153.2296,case rate,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,20565.93,14396.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16491.1425,,,16491.1425,6858.737655,37257.3904,case rate,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,17400.21,12180.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9081.796422,,,9081.796422,5802.970035,20261.9736,case rate,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,17612.23,12328.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8181.686305,,,8181.686305,5873.678705,18195.0456,case rate,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,43267.27,30287.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13286.43249,,,13286.43249,7771.48,34613.816,case rate,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,18403.74,12882.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8065.087154,,,8065.087154,6057.47,17927.5608,case rate,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,61414.22,42989.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19190.58952,,,19190.58952,7771.48,49131.376,case rate,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,15482.04,10837.428,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9525.226528,,,9525.226528,5163.26034,21277.2,case rate,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,13610,9527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6605.831107,,,6605.831107,4538.935,14579.948,case rate,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,148503.39,103952.373,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,61698.04684,,,61698.04684,7771.48,140966.516,case rate,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,33194.92,23236.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17581.1679,,,17581.1679,7771.48,39764.0472,case rate,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,18792.68,13154.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9356.511089,,,9356.511089,6267.35878,20892.184,case rate,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,12279.31,8595.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8716.98241,,,8716.98241,4095.149885,19425.0704,case rate,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,25117.86,17582.502,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15002.73666,,,15002.73666,7771.48,33842.9064,case rate,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,22405.38,15683.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12700.78675,,,12700.78675,7472.19423,28562.108,case rate,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,13917.07,9741.949,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5762.253913,,,5762.253913,3961.38,12646.7624,case rate,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,48007.28,33605.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15979.69622,,,15979.69622,7771.48,38405.824,case rate,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,20565.28,14395.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8042.120655,,,8042.120655,5972.81,17876.9008,case rate,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,61408.52,42985.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35438.50461,,,35438.50461,7771.48,80721.644,case rate,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,26863.69,18804.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18066.9977,,,18066.9977,7771.48,40872.488,case rate,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,27835,19484.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11452.64583,,,11452.64583,7771.48,25698.8048,case rate,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,30162.14,21113.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14544.29,,,14544.29,7771.48,32791.2048,case rate,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42212,29548.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15600.74898,,,15600.74898,7771.48,35214.7792,case rate,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,17347.78,12143.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6115.584675,,,6115.584675,4755.82,13878.224,case rate,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,43962.28,30773.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14733.32196,,,14733.32196,7771.48,35169.824,case rate,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,17818.34,12472.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8063.3205,,,8063.3205,5723.92,17921.4816,case rate,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,31482.85,22037.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16357.76014,,,16357.76014,7771.48,36949.3776,case rate,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,15673.65,10971.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9223.128726,,,9223.128726,5227.162275,20584.1712,case rate,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,7247.46,5073.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6324.049825,,,6324.049825,2417.02791,13933.5264,case rate,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,28001.68,19601.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9258.461802,,,9258.461802,6731.81,22401.344,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC,939,MS-DRG,,,,,,,inpatient,,,23950.54,16765.378,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28286.20666,,,28286.20666,7771.48,64313.8832,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,49540.17,34678.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18899.97497,,,18899.97497,7771.48,42783.3832,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC,941,MS-DRG,,,,,,,inpatient,,,17064.75,11945.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17512.2684,,,17512.2684,5691.094125,39599.9088,case rate,
Rehabilitation With Cc/McC,945,MS-DRG,,,,,,,inpatient,,,45131.85,31592.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13733.3959,,,13733.3959,7771.48,36105.48,case rate,
Rehabilitation Without Cc/McC,946,MS-DRG,,,,,,,inpatient,,,44615.43,31230.801,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10111.75559,,,10111.75559,7771.48,35692.344,case rate,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,22069.35,15448.545,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11610.76135,,,11610.76135,7360.128225,26061.5304,case rate,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,17906.41,12534.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7267.442959,,,7267.442959,5684.12,16099.748,case rate,
Aftercare With Cc/McC,949,MS-DRG,,,,,,,inpatient,,,33492.73,23444.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9780.508003,,,9780.508003,7771.48,26794.184,case rate,
Aftercare Without Cc/McC,950,MS-DRG,,,,,,,inpatient,,,9898.64,6929.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5426.589689,,,5426.589689,3301.19644,11876.7304,case rate,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,4337.06,3035.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5257.87425,,,5257.87425,1446.40951,11487.6616,case rate,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,61892.75,43324.925,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34013.69831,,,34013.69831,7771.48,77453.0608,case rate,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,12905.91,9034.137,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13500.1976,,,13500.1976,4304.120985,30400.0528,case rate,
Other Multiple Significant Trauma Without Cc/McC,965,MS-DRG,,,,,,,inpatient,,,19234.18,13463.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8310.652034,,,8310.652034,6414.59903,18490.9,case rate,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,37958.81,26571.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26627.31873,,,26627.31873,7771.48,60508.304,case rate,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,12545.67,8781.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12986.10134,,,12986.10134,4183.980945,29216.6352,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,108861.48,76203.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,42241.88843,,,42241.88843,7771.48,96341.1352,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,62893.24,31446.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21875.9,,,21875.9,7771.48,50314.592,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,59507.83,29753.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14985.07,,,14985.07,7771.48,47606.264,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51559.92,25779.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31189.7,,,31189.7,7771.48,70984.792,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,16279.53,8139.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15407.3,,,15407.3,5429.223255,34773.024,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,989,MS-DRG,,,,,,,inpatient,,,64497.43,32248.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10456.25,,,10456.25,7771.48,51597.944,case rate,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,17.7355,1592,,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,399.86,2141,other,OPPS APC
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,57.921,1592,other,OPPS APC
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,195.5395,1592,other,OPPS APC
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,155.354,2141,other,OPPS APC
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,291.227805,2141,other,OPPS APC
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,29.185,1592,,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,206.989,1592,other,OPPS APC
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,206.989,1592,other,OPPS APC
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3715.584,other,OPPS APC
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,205.642,1592,other,OPPS APC
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,205.642,1592,other,OPPS APC
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6635.52,other,OPPS APC
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,263.563,1592,other,OPPS APC
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.8985,1592,,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,158.497,3914,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,399.86,2141,other,OPPS APC
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,399.86,2141,other,OPPS APC
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,228.541,1592,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,239.0925,1592,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.0735,1592,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.0735,1592,other,OPPS APC
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1592,other,OPPS APC
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,62.19,1592,other,OPPS APC
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,66.75974,1592,other,OPPS APC
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,47.594,1592,other,OPPS APC
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,96.7595,1592,other,OPPS APC
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.2055,1592,,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,35.6955,1592,other,OPPS APC
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,399.86,1592,other,OPPS APC
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,399.86,2141,other,OPPS APC
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,113.876282,1592,other,OPPS APC
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,156.65,1592,other,OPPS APC
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,113.3725,1592,other,OPPS APC
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,113.3725,1592,other,OPPS APC
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,99.9025,1592,other,OPPS APC
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,115.1685,1592,other,OPPS APC
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,145.476,1592,other,OPPS APC
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,95.4125,1592,other,OPPS APC
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,73.8605,1592,other,OPPS APC
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,89.8,1592,other,OPPS APC
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,107.5355,1592,other,OPPS APC
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,142.1085,1592,other,OPPS APC
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,174.8855,1592,other,OPPS APC
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,124.5975,1592,other,OPPS APC
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,100.576,1592,other,OPPS APC
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,309.1365,1592,other,OPPS APC
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,181.6205,1592,other,OPPS APC
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,200.0295,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,113.3725,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,153.7825,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,153.7825,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,145.7005,1592,other,OPPS APC
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,142.333,1592,other,OPPS APC
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,142.1085,1592,other,OPPS APC
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,139.8635,1592,other,OPPS APC
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,140.7615,1592,other,OPPS APC
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,237.072,2141,other,OPPS APC
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,4022.784,other,OPPS APC
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,200.0295,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,133.802,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,148.8435,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,146.374,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,168.1505,1592,other,OPPS APC
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,318.5655,1592,other,OPPS APC
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,254.134,1592,other,OPPS APC
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,399.86,1592,other,OPPS APC
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,244.705,1592,other,OPPS APC
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,56.125,1592,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,395.3445,1592,other,OPPS APC
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,165.0075,1592,other,OPPS APC
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,68.4725,1592,,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,257.0525,1592,other,OPPS APC
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,162.3135,1592,other,OPPS APC
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.761,1592,,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,395.3445,1592,other,OPPS APC
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,166.8035,1592,other,OPPS APC
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,103.719,1592,,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,108.7,1592,other,OPPS APC
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,5804.544,other,OPPS APC
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3915.61683,,,3915.61683,399.86,7323.648,other,OPPS APC
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,4478.208,other,OPPS APC
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,5804.544,other,OPPS APC
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3915.61683,,,3915.61683,399.86,5481.863562,other,OPPS APC
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,7323.648,other,OPPS APC
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,5804.544,other,OPPS APC
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,88.2285,1592,other,OPPS APC
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,182.294,1592,other,OPPS APC
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,182.294,1592,other,OPPS APC
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,189.7025,1592,other,OPPS APC
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.415,2998,,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,395.7935,1592,other,OPPS APC
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.47,1592,other,OPPS APC
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3315.456,other,OPPS APC
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3070.464,other,OPPS APC
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1794.048,other,OPPS APC
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3932.16,other,OPPS APC
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1714.176,other,OPPS APC
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,108.7,2998,other,OPPS APC
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,197.56,1592,other,OPPS APC
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,108.7,2141,other,OPPS APC
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.858,1592,,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,108.7,2141,other,OPPS APC
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,61.513,1592,other,OPPS APC
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,108.7,2141,other,OPPS APC
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10288.44571,,,10288.44571,399.86,14403.82399,other,OPPS APC
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2954.496,other,OPPS APC
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4449.024,other,OPPS APC
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,184.7635,1592,other,OPPS APC
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,202.7235,1592,other,OPPS APC
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,147.721,1592,other,OPPS APC
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,160.293,1592,other,OPPS APC
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,160.293,1592,other,OPPS APC
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,210.581,1592,other,OPPS APC
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,169.0485,1592,other,OPPS APC
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,169.0485,1592,other,OPPS APC
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,399.86,2141,other,OPPS APC
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,147.721,1592,other,OPPS APC
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,147.721,1592,other,OPPS APC
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,176.008,1592,other,OPPS APC
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14364.36381,,,14364.36381,399.86,20110.10933,other,OPPS APC
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3683.328,other,OPPS APC
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,380.5275,1592,,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.382395,,,257.382395,165.0075,1592,other,OPPS APC
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,2998,other,OPPS APC
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,274.788,1592,,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7808.106015,,,7808.106015,399.86,16604.928,other,OPPS APC
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,2455.793921,other,OPPS APC
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2841.6,other,OPPS APC
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2841.6,other,OPPS APC
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.382395,,,257.382395,202.499,1592,other,OPPS APC
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,2455.793921,other,OPPS APC
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.382395,,,257.382395,150.6395,1592,other,OPPS APC
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,2998,other,OPPS APC
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.382395,,,257.382395,160.5175,1592,other,OPPS APC
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,5885.184,other,OPPS APC
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,324.627,1592,other,OPPS APC
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,187.233,1592,other,OPPS APC
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,292.65,2813.184,other,OPPS APC
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,293.11054,,,293.11054,149.068,1592,other,OPPS APC
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,293.11054,,,293.11054,200.4785,1592,other,OPPS APC
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,110.2295,1592,other,OPPS APC
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,114.7195,1592,other,OPPS APC
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,101.6985,1592,other,OPPS APC
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,79.473,1592,other,OPPS APC
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,79.473,1592,other,OPPS APC
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,49.6145,1592,other,OPPS APC
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,48.941,1592,other,OPPS APC
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,90.9225,1592,other,OPPS APC
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,27.389,1592,other,OPPS APC
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,27.389,1592,other,OPPS APC
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,293.11054,,,293.11054,156.9255,1592,other,OPPS APC
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,124.373,1592,other,OPPS APC
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,79.473,1592,other,OPPS APC
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,77.9015,1592,other,OPPS APC
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,77.9015,1592,other,OPPS APC
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,64.8805,1592,other,OPPS APC
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,64.8805,1592,other,OPPS APC
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,109.107,1592,other,OPPS APC
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,114.495,1592,other,OPPS APC
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,122.128,1592,other,OPPS APC
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,122.128,1592,other,OPPS APC
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,122.128,1592,other,OPPS APC
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,138.0675,1592,other,OPPS APC
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,216.190215,,,216.190215,83.2895,1592,other,OPPS APC
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1852.43387,,,1852.43387,399.86,3022.08,other,OPPS APC
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3528.192,other,OPPS APC
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,399.86,2141,other,OPPS APC
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1512.300555,,,1512.300555,399.86,3224.064,other,OPPS APC
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,399.86,2141,other,OPPS APC
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,367.282,2141,other,OPPS APC
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,367.282,2141,other,OPPS APC
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2076.780045,,,2076.780045,399.86,2998,other,OPPS APC
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,399.86,1739.52,other,OPPS APC
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4252.416,other,OPPS APC
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4252.416,other,OPPS APC
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,28237.056,other,OPPS APC
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21266.60843,,,21266.60843,399.86,37615.872,other,OPPS APC
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,2998,other,OPPS APC
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6364,other,OPPS APC
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,13659.648,other,OPPS APC
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,16316.30039,other,OPPS APC
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21266.60843,,,21266.60843,399.86,29773.2518,other,OPPS APC
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25726.38358,,,25726.38358,399.86,51836.928,other,OPPS APC
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35906.82009,,,35906.82009,399.86,50269.54813,other,OPPS APC
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6933.504,other,OPPS APC
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35906.82009,,,35906.82009,399.86,66342.912,other,OPPS APC
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25726.38358,,,25726.38358,399.86,48388.608,other,OPPS APC
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25726.38358,,,25726.38358,399.86,50497.536,other,OPPS APC
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35906.82009,,,35906.82009,399.86,50497.536,other,OPPS APC
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21295.104,other,Status Indicator C
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24913.5068,,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21295.104,,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,22573.824,,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,22573.824,,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24913.5068,,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23502.2528,,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24913.5068,,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24913.5068,,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5338.368,,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4584.96,,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3746.392,,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,370.2005,2998,,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3237.832,,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3220.992,,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6913,,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.2055,6913,,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3155.712,,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3549.7488,,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3549.7488,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3155.712,,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,293.5896,3216.384,,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,397.365,2141,other,OPPS APC
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,397.365,2141,other,OPPS APC
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.124,2998,,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.431,2998,,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,37.4915,2998,,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,75.6565,2998,,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.3515,2998,,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.941,2998,,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,77.0035,1592,other,OPPS APC
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,173.9875,2141,other,OPPS APC
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,57.921,1592,other,OPPS APC
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,121.4545,1592,other,OPPS APC
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,173.5385,1592,other,OPPS APC
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,204.0705,1592,other,OPPS APC
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6398.208,,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,161.8645,1592,,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,373.119,1592,other,OPPS APC
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,140.986,1592,,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,76.33,1592,other,OPPS APC
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2003.712,,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,161.8645,1592,other,OPPS APC
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.235,1592,other,OPPS APC
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.516,1592,other,OPPS APC
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,346.8525,1592,other,OPPS APC
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.4705,1592,other,OPPS APC
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7442.688,other,OPPS APC
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7442.688,other,OPPS APC
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,8396.844904,other,OPPS APC
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,12170.496,other,OPPS APC
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7020.288,other,OPPS APC
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,12170.496,other,OPPS APC
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,115.6175,1592,,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.394,1592,,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.5215,1592,other,OPPS APC
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,277.482,1592,other,OPPS APC
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,323.729,1592,other,OPPS APC
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,57.921,1592,other,OPPS APC
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,8396.844904,other,OPPS APC
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.388,416.02,,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,473.790255,,,473.790255,207.2135,1592,other,OPPS APC
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,156.65,1592,other,OPPS APC
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,204.0705,1592,other,OPPS APC
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,85.9835,1592,other,OPPS APC
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6623.08,other,OPPS APC
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1592,,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1592,,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,205.4175,1592,,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,92.494,1592,,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,173.5385,1592,,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,473.790255,,,473.790255,300.1565,2081.64,other,OPPS APC
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1674.594995,,,1674.594995,399.86,3777.792,other,OPPS APC
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2953.728,other,OPPS APC
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2953.728,other,OPPS APC
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2998,other,OPPS APC
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,35.92,1592,other,OPPS APC
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,28.0625,1592,other,OPPS APC
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,180.947,1592,other,OPPS APC
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,91.147,1592,other,OPPS APC
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,66.6765,1592,other,OPPS APC
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,69.3705,1592,other,OPPS APC
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9071.0152,,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,127.516,1592,other,OPPS APC
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,127.516,1592,other,OPPS APC
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5756,,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,18955.84,other,OPPS APC
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,184.988,4800.911611,other,OPPS APC
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,277.482,8164.18419,other,OPPS APC
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6788.57,other,OPPS APC
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,10775.04,other,OPPS APC
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7394.304,other,OPPS APC
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7678.464,other,OPPS APC
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,137.6185,1592,other,OPPS APC
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6777.6,other,OPPS APC
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5548.032,other,OPPS APC
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5548.032,other,OPPS APC
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,124.1485,2998,,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,12283.392,other,OPPS APC
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,18955.84,other,OPPS APC
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12148.224,other,OPPS APC
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12453.888,other,OPPS APC
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,12748.032,other,OPPS APC
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,25020.672,other,OPPS APC
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,45315.84,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,44656.128,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12327.936,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,25786.368,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12327.936,other,OPPS APC
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12148.224,,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4532,other,OPPS APC
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4532,other,OPPS APC
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3565.824,other,OPPS APC
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,85.5345,1592,,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.25,1592,,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,121.23,1592,other,OPPS APC
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,95.188,1592,,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,600.505465,,,600.505465,119.6585,1592,other,OPPS APC
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,153.7825,1592,other,OPPS APC
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,72.9625,1592,other,OPPS APC
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,72.9625,1592,other,OPPS APC
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,129.9855,1592,other,OPPS APC
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,111.352,1592,other,OPPS APC
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,375.5885,2998,other,OPPS APC
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1287.95438,,,1287.95438,399.86,4005.9,other,OPPS APC
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3064.48742,,,3064.48742,399.86,4934.4,other,OPPS APC
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1287.95438,,,1287.95438,399.86,2998,other,OPPS APC
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,218.214,1592,,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6297.489345,,,6297.489345,399.86,10219.776,other,OPPS APC
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11234.78908,,,11234.78908,399.86,15728.70471,other,OPPS APC
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,390.63,2998,other,Status Indicator C
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6577.152,,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6577.152,,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,207.6625,2998,other,OPPS APC
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,367.0575,2998,other,OPPS APC
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,367.0575,2998,other,OPPS APC
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6116.352,other,OPPS APC
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,110.2295,1592,other,OPPS APC
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,369.078,2998,other,OPPS APC
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,369.078,2998,other,OPPS APC
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,379.854,2998,other,OPPS APC
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,379.854,2998,other,OPPS APC
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,2998,other,OPPS APC
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,2998,other,OPPS APC
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,2998,other,OPPS APC
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,136.047,1592,other,OPPS APC
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,4179.83,other,OPPS APC
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,745.56013,,,745.56013,339.6685,2141,other,OPPS APC
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,162.987,2141,other,OPPS APC
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,119.6585,1592,other,OPPS APC
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,745.56013,,,745.56013,334.48,2141,other,OPPS APC
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,4225.536,other,OPPS APC
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6297.489345,,,6297.489345,399.86,10219.776,other,OPPS APC
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,83.963,1592,other,OPPS APC
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,119.6585,1592,other,OPPS APC
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,156.9255,1592,other,OPPS APC
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,156.9255,1592,other,OPPS APC
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1141.12419,,,1141.12419,179.53,2998,other,OPPS APC
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1141.12419,,,1141.12419,179.53,2998,other,OPPS APC
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,219.112,1592,other,OPPS APC
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,87.3305,1592,other,OPPS APC
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,87.7795,1592,other,OPPS APC
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,79.473,1592,other,OPPS APC
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,102.372,1592,other,OPPS APC
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,106.6375,1592,other,OPPS APC
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,47.594,1592,other,OPPS APC
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3804.86989,,,3804.86989,399.86,6210.048,other,OPPS APC
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,5068.032,other,OPPS APC
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,120.28264,1592,other,OPPS APC
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,350.13353,,,350.13353,186.1105,1592,other,OPPS APC
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3412.181035,,,3412.181035,399.86,4777.053449,other,OPPS APC
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3412.181035,,,3412.181035,399.86,5299.2,other,OPPS APC
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,217.48463,,,217.48463,110.005,416.02,other,OPPS APC
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3412.181035,,,3412.181035,399.86,4777.053449,other,OPPS APC
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3412.181035,,,3412.181035,399.86,5511.168,other,OPPS APC
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,339.893,2141,other,OPPS APC
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6297.489345,,,6297.489345,399.86,11413.04,other,OPPS APC
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,399.86,2141,other,OPPS APC
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,119.6585,5756,,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,281.972,2141,other,OPPS APC
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,281.972,2141,other,OPPS APC
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,294.544,1592,,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2107.296165,,,2107.296165,399.86,6224.0876,other,OPPS APC
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,281.972,1592,,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.5215,1592,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,325.997845,,,325.997845,155.844464,1592,other,OPPS APC
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,200.0295,1592,other,OPPS APC
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,323.2601,1592,other,OPPS APC
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,196.8865,1592,other,OPPS APC
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,346.628,2141,other,OPPS APC
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,346.628,2141,other,OPPS APC
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,346.628,2141,other,OPPS APC
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,310.259,2141,other,OPPS APC
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,346.628,2141,other,OPPS APC
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,346.628,2141,other,OPPS APC
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,399.86,2141,other,OPPS APC
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,346.628,2141,other,OPPS APC
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,4677.12,other,OPPS APC
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,366.833,2141,other,OPPS APC
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,185.2125,1592,other,OPPS APC
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.635,1592,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,93.392,1592,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,49.6145,1592,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.288,1592,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,380.0785,1592,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.123,1592,,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,154.2315,1592,other,OPPS APC
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,154.2315,1592,other,OPPS APC
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,46.0225,1592,other,OPPS APC
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,66.75974,1592,other,OPPS APC
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,60.8395,416.02,other,OPPS APC
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,456.96,other,OPPS APC
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.208,416.02,other,OPPS APC
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,66.2275,416.02,other,OPPS APC
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,56.574,416.02,other,OPPS APC
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,73.636,416.02,other,OPPS APC
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,549.888,other,OPPS APC
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1987.584,other,OPPS APC
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,120.5565,646.6965,other,OPPS APC
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,89.81,821.76,other,OPPS APC
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,124.33,1023.744,other,OPPS APC
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,153.75,1240.32,other,OPPS APC
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,575,other,OPPS APC
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,173.763,667.43,other,OPPS APC
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1243.392,other,OPPS APC
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,921.6,other,OPPS APC
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1014.528,other,OPPS APC
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,889.344,other,OPPS APC
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,575,other,OPPS APC
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,194.55,1138.176,other,OPPS APC
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1347.84,other,OPPS APC
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1021.44,other,OPPS APC
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,888.576,other,OPPS APC
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,3902.208,other,OPPS APC
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,365.99,2081.28,other,OPPS APC
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,379.854,1299.456,other,OPPS APC
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1750.272,other,OPPS APC
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,374.62,1750.272,other,OPPS APC
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,301.425681,1750.272,other,OPPS APC
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1675.776,other,OPPS APC
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.86,1896.192,other,OPPS APC
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,301.425681,1946.112,other,OPPS APC
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,188.66,1605.12,other,OPPS APC
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,268.7,4035.84,other,OPPS APC
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,307.14,2049.024,other,OPPS APC
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,48.043,416.02,other,OPPS APC
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,55.0025,416.02,other,OPPS APC
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,431.616,other,OPPS APC
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,56.125,416.02,other,OPPS APC
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,1065.984,other,OPPS APC
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,195.34,1247.232,other,OPPS APC
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1522.176,other,OPPS APC
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,59.268,575,other,OPPS APC
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1222.656,other,OPPS APC
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,1519.872,other,OPPS APC
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,399.86,2402.304,other,OPPS APC
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,347.3015,1288.93,other,OPPS APC
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1817.856,other,OPPS APC
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1817.856,other,OPPS APC
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1817.856,other,OPPS APC
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,56.3495,416.02,other,OPPS APC
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,66.452,416.02,other,OPPS APC
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,67.35,416.02,other,OPPS APC
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,67.35,416.02,other,OPPS APC
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,56.574,416.02,other,OPPS APC
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,63.5335,416.02,other,OPPS APC
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,581.376,other,OPPS APC
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,581.376,other,OPPS APC
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,52.7575,416.02,other,OPPS APC
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,72.5135,416.02,other,OPPS APC
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,462.336,other,OPPS APC
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,92.2695,416.02,other,OPPS APC
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,1043.712,other,OPPS APC
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,196.52,1195.008,other,OPPS APC
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1719.552,other,OPPS APC
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,698.112,other,OPPS APC
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,196.52,796.416,other,OPPS APC
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1704.192,other,OPPS APC
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,575,other,OPPS APC
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,195.73,1095.936,other,OPPS APC
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1057.536,other,OPPS APC
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,185.92,1624.32,other,OPPS APC
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,270.27,2337.024,other,OPPS APC
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,185.92,1706.496,other,OPPS APC
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,266.73,2183.424,other,OPPS APC
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,185.92,2035.968,other,OPPS APC
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,265.17,2031.36,other,OPPS APC
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,307.53,2399.232,other,OPPS APC
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,307.93,2175.744,other,OPPS APC
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,305.58,2443.008,other,OPPS APC
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,64.4315,416.02,other,OPPS APC
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,974.592,other,OPPS APC
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,1050.624,other,OPPS APC
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,195.33,1198.848,other,OPPS APC
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1460.736,other,OPPS APC
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,1721.088,other,OPPS APC
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,372.27,2188.8,other,OPPS APC
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2114.304,other,OPPS APC
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2233.344,,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2233.344,,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2233.344,,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,331.811,2051.3855,other,OPPS APC
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,399.86,2051.3855,other,OPPS APC
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,395.12,2051.3855,other,OPPS APC
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,399.86,2051.3855,other,OPPS APC
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2107.296165,,,2107.296165,399.86,4977.9345,other,OPPS APC
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2107.296165,,,2107.296165,399.86,4977.9345,other,OPPS APC
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,38.165,416.02,other,OPPS APC
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,57.472,416.02,other,OPPS APC
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,31.2055,416.02,other,OPPS APC
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,379.405,1297.92,other,OPPS APC
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,39.961,416.02,other,OPPS APC
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,38.3895,416.02,other,OPPS APC
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,28.9605,416.02,other,OPPS APC
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,298.8095,1022.208,other,OPPS APC
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,50.5125,416.02,other,OPPS APC
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,42.655,416.02,other,OPPS APC
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1322.496,other,OPPS APC
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.982,416.02,other,OPPS APC
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,28.9605,416.02,other,OPPS APC
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,736.512,other,OPPS APC
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,193.37,1065.984,other,OPPS APC
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1506.048,other,OPPS APC
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1032.96,other,OPPS APC
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,2217.984,other,OPPS APC
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,371.09,2254.848,other,OPPS APC
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2414.592,other,OPPS APC
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,204.76,2333.952,other,OPPS APC
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,340.49,2414.592,other,OPPS APC
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2350.08,other,OPPS APC
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,49.839,416.02,other,OPPS APC
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,49.839,416.02,other,OPPS APC
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,581.376,other,OPPS APC
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1241.088,other,OPPS APC
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,47.8185,416.02,other,OPPS APC
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,47.8185,416.02,other,OPPS APC
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,58.37,416.02,other,OPPS APC
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,382.548,1308.672,other,OPPS APC
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,44.6755,416.02,other,OPPS APC
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,51.8595,416.02,other,OPPS APC
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,30.7565,416.02,other,OPPS APC
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,29.185,416.02,other,OPPS APC
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,35.471,416.02,other,OPPS APC
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,36.818,416.02,other,OPPS APC
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.533,416.02,other,OPPS APC
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,43.104,416.02,other,OPPS APC
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,743.424,other,OPPS APC
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,196.51,758.016,other,OPPS APC
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1461.504,other,OPPS APC
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,903.168,other,OPPS APC
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,2178.048,other,OPPS APC
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,372.66,1840.128,other,OPPS APC
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2350.08,other,OPPS APC
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,205.15,2310.144,other,OPPS APC
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,345.98,2317.824,other,OPPS APC
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2379.264,other,OPPS APC
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2290.176,other,OPPS APC
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2290.176,other,OPPS APC
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2290.176,other,OPPS APC
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,92.045,416.02,other,OPPS APC
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,1112.832,other,OPPS APC
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,194.55,1218.048,other,OPPS APC
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1580.544,other,OPPS APC
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,329.339098,1982.208,other,OPPS APC
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1040.64,other,OPPS APC
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,142.38,1050.624,other,OPPS APC
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,204.61123,1513.728,other,OPPS APC
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,204.61123,1629.696,other,OPPS APC
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,1810.176,other,OPPS APC
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,3902.208,other,OPPS APC
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2072.064,other,OPPS APC
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1878.528,other,OPPS APC
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1878.528,other,OPPS APC
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1878.528,other,OPPS APC
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,76.026473,753.408,other,OPPS APC
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,128.66,671.232,other,OPPS APC
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,259.7465,888.576,,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,703.488,other,OPPS APC
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,194.1925,664.32,other,OPPS APC
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,128.66,2264.832,other,OPPS APC
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,183.14,907.776,other,OPPS APC
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,822.528,other,OPPS APC
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1350.144,other,OPPS APC
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,1026.048,other,OPPS APC
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,64.8805,416.02,,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,797.184,other,OPPS APC
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.08,669.696,,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,260.23,2237.184,,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,141.6595,484.608,other,OPPS APC
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1890.816,,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,134.4755,499.422,other,OPPS APC
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1595.904,other,OPPS APC
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.86,2172.672,other,OPPS APC
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,171.069,646.6965,other,OPPS APC
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,171.069,646.6965,other,OPPS APC
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,121.679,1393.3385,other,OPPS APC
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,5136.771,other,OPPS APC
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.819698,1301.76,other,OPPS APC
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,285.115,975.36,,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,88.902,1706.496,other,OPPS APC
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,88.902,1706.496,other,OPPS APC
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,102.5965,2030.592,other,OPPS APC
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,102.5965,2030.592,other,OPPS APC
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.2045,836,,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.2045,836,,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,19.0825,575,other,OPPS APC
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,19.0825,575,other,OPPS APC
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,58.819,669.696,other,OPPS APC
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,58.819,669.696,other,OPPS APC
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,58.819,780.288,other,OPPS APC
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,58.819,780.288,other,OPPS APC
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,57.921,824.064,other,OPPS APC
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,57.921,824.064,other,OPPS APC
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1141.12419,,,1141.12419,399.86,2536.61118,other,OPPS APC
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1321.728,other,OPPS APC
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2717.184,other,OPPS APC
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,92.2695,416.02,other,OPPS APC
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,399.86,3400.704,other,OPPS APC
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,367.731,1602.0655,other,OPPS APC
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,1947.648,other,OPPS APC
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,260.23,8249.769,other,OPPS APC
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,260.23,3665.664,,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,105.7395,416.02,,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,324.627,1110.528,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,294.544,1007.616,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,189.7025,648.96,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,167.028,571.392,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,2241.024,other,OPPS APC
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,2215.68,other,OPPS APC
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,681.984,other,OPPS APC
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,681.984,other,OPPS APC
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,195.08,765.696,other,OPPS APC
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,237.819698,1497.6,other,OPPS APC
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,220.908,1393.3385,other,OPPS APC
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,85.759,416.02,other,OPPS APC
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.024,836,other,OPPS APC
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.024,836,other,OPPS APC
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.024,836,other,OPPS APC
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,94.739,836,other,OPPS APC
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,94.739,836,other,OPPS APC
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,94.739,836,other,OPPS APC
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,712.704,other,OPPS APC
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,81.08,1703.424,other,OPPS APC
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,189.029,836,other,OPPS APC
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,51.4105,575,other,OPPS APC
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,97.2085,416.02,other,OPPS APC
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,99.678,416.02,other,OPPS APC
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,93.6165,416.02,other,OPPS APC
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,103.4945,416.02,other,OPPS APC
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.5545,416.02,other,OPPS APC
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,58.5945,416.02,other,OPPS APC
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,82.616,416.02,other,OPPS APC
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,77.4525,416.02,other,OPPS APC
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,456.96,other,OPPS APC
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,64.8805,416.02,other,OPPS APC
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.288,416.02,other,OPPS APC
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,94.5145,416.02,other,OPPS APC
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.086513,547.584,other,OPPS APC
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,162.7625,646.6965,other,OPPS APC
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,68.0235,416.02,other,OPPS APC
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,460.8,other,OPPS APC
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,79.6975,416.02,other,OPPS APC
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,98.5555,416.02,other,OPPS APC
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,80.371,416.02,other,OPPS APC
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,65.105,416.02,other,OPPS APC
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,443.904,other,OPPS APC
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,32.777,416.02,other,OPPS APC
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,81.9425,416.02,other,OPPS APC
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,199.512292,772.608,other,OPPS APC
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,81.0445,416.02,other,OPPS APC
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,74.534,416.02,other,OPPS APC
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,102.5965,416.02,other,OPPS APC
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,90.0245,416.02,other,OPPS APC
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,61.2885,416.02,other,OPPS APC
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,89.8,416.02,other,OPPS APC
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,56.7985,416.02,other,OPPS APC
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,152.8845,775.5705,other,OPPS APC
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,56.3495,416.02,other,OPPS APC
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,103.27,416.02,other,OPPS APC
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,166.37,666.624,other,OPPS APC
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.473,416.02,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,135.598,463.872,other,OPPS APC
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,116.9645,416.02,other,OPPS APC
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,71.391,416.02,other,OPPS APC
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,116.291,416.02,other,OPPS APC
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1383.168,other,OPPS APC
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.344499,1341.696,other,OPPS APC
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.344499,1347.84,other,OPPS APC
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,139.8635,575,other,OPPS APC
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2374.656,,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,189.029,836,other,OPPS APC
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,189.029,836,other,OPPS APC
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.547552,1936.896,other,OPPS APC
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.547552,1936.896,other,OPPS APC
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.547552,2548.224,other,OPPS APC
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.547552,2548.224,other,OPPS APC
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,72.0645,416.02,fee schedule,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,88.2285,416.02,fee schedule,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25.43,,,25.43,22.99364,416.02,fee schedule,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,92.45,,,92.45,88.2285,416.02,fee schedule,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,118.49,,,118.49,90.800319,416.02,fee schedule,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,97.74,,,97.74,90.800319,416.02,fee schedule,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,48.941,416.02,other,OPPS APC
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,112.699,416.02,other,OPPS APC
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,112.699,416.02,other,OPPS APC
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,441.6,other,OPPS APC
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,25.593,416.02,other,OPPS APC
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1847.808,other,OPPS APC
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,55.676,416.02,other,OPPS APC
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,55.676,416.02,other,OPPS APC
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,209.9075,1076.394,other,OPPS APC
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,142.1085,1076.394,other,OPPS APC
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,220.459,1076.394,other,OPPS APC
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,235.5005,1397.122,other,OPPS APC
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,38.3895,416.02,,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,353.5875,1209.6,other,OPPS APC
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,304.6465,1076.394,other,OPPS APC
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,358.69,1457.664,other,OPPS APC
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,314.9735,1077.504,other,OPPS APC
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,314.9735,1077.504,other,OPPS APC
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,147.9455,1076.394,other,OPPS APC
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,217.9895,1076.394,other,OPPS APC
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,240.4395,1397.122,other,OPPS APC
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,399.86,2239.93036,other,OPPS APC
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,270.5225,1076.394,other,OPPS APC
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,310.708,1076.394,other,OPPS APC
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,310.708,1397.122,other,OPPS APC
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,176.906,1076.394,other,OPPS APC
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,234.1535,1076.394,other,OPPS APC
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,188.131,1076.394,other,OPPS APC
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,399.86,1596.672,other,OPPS APC
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,200.4785,1076.394,other,OPPS APC
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,214.173,1076.394,other,OPPS APC
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,215.969,1076.394,other,OPPS APC
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,246.501,1076.394,other,OPPS APC
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,200.4785,1076.394,other,OPPS APC
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,214.622,1076.394,other,OPPS APC
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,356.057,1218.048,other,OPPS APC
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,375.1395,1283.328,other,OPPS APC
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,172.1915,1076.394,other,OPPS APC
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,143.68,1076.394,other,OPPS APC
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,212.377,1397.122,other,OPPS APC
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,202.499,1076.394,other,OPPS APC
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,336.5255,1397.122,other,OPPS APC
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,399.86,2076.672,other,OPPS APC
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,356.7305,1397.122,other,OPPS APC
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,3755.52,other,OPPS APC
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,399.86,1973.76,other,OPPS APC
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,205.642,1397.122,other,OPPS APC
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,290.054,1076.394,other,OPPS APC
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,271.645,1397.122,other,OPPS APC
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,201.8255,1397.122,other,OPPS APC
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,189.7025,1076.394,other,OPPS APC
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,194.6415,1076.394,other,OPPS APC
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,275.4615,1076.394,other,OPPS APC
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,3982.848,other,OPPS APC
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,5302.272,other,OPPS APC
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,5917.44,other,OPPS APC
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,4124.5085,other,OPPS APC
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.5735,416.02,,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,271.52932,,,271.52932,175.559,691.5815,other,OPPS APC
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.29,24.576,fee schedule,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.286,21.504,fee schedule,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,185.2,,,185.2,160.742,549.888,fee schedule,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.33,18.432,,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.4,34.56,fee schedule,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,938.496695,,,938.496695,39.73,1313.895373,other,OPPS APC
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.35,61.44,fee schedule,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.78,24.576,,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.6125,19.2,fee schedule,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.77,98.304,fee schedule,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.51,121.344,,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.5105,24.43,fee schedule,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.4085,25.344,,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.71,119.04,fee schedule,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.37,193.536,fee schedule,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,27.838,95.232,,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,64.4315,241.472,,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,59.142165,,,59.142165,6.25,92.88556,other,OPPS APC
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.072,274.944,other,OPPS APC
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,392.31084,,,392.31084,2.842,549.235176,other,OPPS APC
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,5.5,93.463636,other,OPPS APC
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,5.85,274.176,other,OPPS APC
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,5.29,274.176,other,OPPS APC
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,3.05,195.186327,other,OPPS APC
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,3.05,65.28,other,OPPS APC
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,392.31084,,,392.31084,3.91,549.235176,other,OPPS APC
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,9.71,238.848,other,OPPS APC
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,392.31084,,,392.31084,3.91,549.235176,other,OPPS APC
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,7.91,218.112,other,OPPS APC
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.31,272.64,other,OPPS APC
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.072,274.176,other,OPPS APC
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.45,274.176,other,OPPS APC
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,1.862,274.176,other,OPPS APC
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,1.302,263.69806,other,OPPS APC
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,1.932,416.02,other,OPPS APC
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,1.932,93.463636,other,OPPS APC
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,1.54,499.62884,other,OPPS APC
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.702,274.944,other,OPPS APC
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,2.072,608.812631,other,OPPS APC
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32.497835,,,32.497835,2.31,238.848,other,OPPS APC
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.31,416.02,other,OPPS APC
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.31,416.02,other,OPPS APC
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,2.31,238.848,other,OPPS APC
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32.497835,,,32.497835,1.68,229.632,other,OPPS APC
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.674,39.936,,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,59.142165,,,59.142165,47.145,416.02,other,OPPS APC
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,59.142165,,,59.142165,34.124,116.736,other,OPPS APC
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.32,44.544,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,389.10344,,,389.10344,389.10344,4791.979,other,OPPS APC
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,43.3285,416.02,other,OPPS APC
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.3885,416.02,other,OPPS APC
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47.56116,,,47.56116,24.9195,416.02,other,OPPS APC
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,671.54688,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,671.54688,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.48,416.02,other,OPPS APC
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.48,416.02,other,OPPS APC
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.799745,416.02,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.799745,416.02,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.07683,416.02,other,OPPS APC
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.07683,416.02,other,OPPS APC
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,881.02656,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,881.02656,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,843.5712,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.135995,416.02,other,OPPS APC
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.135995,416.02,other,OPPS APC
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,54.47,416.02,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,54.47,416.02,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,566.10816,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,566.10816,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,492.14208,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,492.14208,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,252.787,1055.807021,other,OPPS APC
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,398.4875,1363.2,other,OPPS APC
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,3012.096,other,OPPS APC
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,3012.096,other,OPPS APC
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,168.824,1592,other,OPPS APC
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,305.32,1592,other,OPPS APC
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,417.629472,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,417.629472,,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,17.96,416.02,other,OPPS APC
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,163,975.36,other,OPPS APC
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,163,677.376,other,OPPS APC
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,123.475,422.4,other,OPPS APC
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,34.7975,416.02,other,OPPS APC
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,34.7975,416.02,other,OPPS APC
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,34.7975,416.02,other,OPPS APC
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,142.97,534.528,other,OPPS APC
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.5125,416.02,,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,60.3905,416.02,other,OPPS APC
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,51.635,416.02,other,OPPS APC
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,61.17,416.02,other,OPPS APC
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,32.328,416.02,other,OPPS APC
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,29.634,416.02,other,OPPS APC
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,116.5155,416.02,other,OPPS APC
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.8575,416.02,,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,21.3275,416.02,other,OPPS APC
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,28.0625,416.02,other,OPPS APC
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,80.5955,416.02,other,OPPS APC
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,112.25,416.02,other,OPPS APC
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,114.7195,416.02,other,OPPS APC
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,25.593,416.02,other,OPPS APC
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,128.12716,479.602522,other,OPPS APC
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.042,416.02,,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,36.369,416.02,,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,84.99,559.872,other,OPPS APC
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.01,416.02,other,OPPS APC
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,128.12716,662.784,other,OPPS APC
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,128.12716,662.784,other,OPPS APC
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,13488.384,other,OPPS APC
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13488.384,other,OPPS APC
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,25715.712,other,OPPS APC
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,25231.872,,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,25024.512,other,OPPS APC
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,20484.864,,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,20097.792,,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20484.864,other,OPPS APC
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,20097.792,,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,19712.256,other,OPPS APC
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,20097.792,other,OPPS APC
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,232.133,997.822944,other,OPPS APC
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,232.133,997.822944,other,OPPS APC
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,710.32455,,,710.32455,292.299,999.936,other,OPPS APC
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,710.32455,,,710.32455,399.86,1540.608,other,OPPS APC
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,710.32455,,,710.32455,399.86,1540.608,other,OPPS APC
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,173.5385,593.664,,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,2138.88,other,OPPS APC
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,2138.88,other,OPPS APC
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,169.4975,1592,other,OPPS APC
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,169.4975,1592,other,OPPS APC
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,13233.408,other,OPPS APC
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,25.49469,416.02,other,OPPS APC
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.286,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,108.8825,479.602522,other,OPPS APC
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,25.49469,416.02,other,OPPS APC
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.939,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,84.459332,416.02,other,OPPS APC
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,66.75974,416.02,other,OPPS APC
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.1435,416.02,fee schedule,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,41.157815,934.656,other,OPPS APC
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,41.157815,1442.304,other,OPPS APC
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,41.157815,416.02,other,OPPS APC
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32.497835,,,32.497835,23.39896,416.02,other,OPPS APC
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1223.3,other,OPPS APC
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1223.3,other,OPPS APC
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,281.81,1040.64,other,OPPS APC
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,281.81,1040.64,other,OPPS APC
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,943.104,other,OPPS APC
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,943.104,other,OPPS APC
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1354.752,other,OPPS APC
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1354.752,other,OPPS APC
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,336.9745,1152.768,other,OPPS APC
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.024,416.02,,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,72.5135,416.02,other,OPPS APC
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,86.208,416.02,other,OPPS APC
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,135.906309,571.392,other,OPPS APC
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1062.912,other,OPPS APC
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1062.912,other,OPPS APC
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1370.88,other,OPPS APC
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1370.88,other,OPPS APC
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.661,597.504,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,241.7865,827.136,other,OPPS APC
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7960.32,other,OPPS APC
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2532.39,other,OPPS APC
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2532.39,other,OPPS APC
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1952.256,,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,228.541,1592,,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,114.495,1592,,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,228.541,1592,other,OPPS APC
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5638.7,other,OPPS APC
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1575.168,other,OPPS APC
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,40899.072,other,OPPS APC
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,40899.072,other,OPPS APC
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,40542.72,other,OPPS APC
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,40542.72,other,OPPS APC
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12978.432,,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6909.98,,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4525.056,,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2361.6,other,OPPS APC
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1298.939725,,,1298.939725,399.86,2367.744,other,OPPS APC
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,399.86,2367.744,other,OPPS APC
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10671.09667,other,OPPS APC
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,325.997845,,,325.997845,73.54,934.656,other,OPPS APC
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,144.21845,,,144.21845,57.2475,416.02,other,OPPS APC
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,144.21845,,,144.21845,60.8395,416.02,other,OPPS APC
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,255.2565,873.216,other,OPPS APC
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.086,686,other,OPPS APC
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,213.724,731.136,other,OPPS APC
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,135.906309,702.72,other,OPPS APC
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,121.132463,686,other,OPPS APC
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,135.906309,775.5705,other,OPPS APC
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,99.0045,686,other,OPPS APC
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,135.906309,686,other,OPPS APC
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,135.906309,686,other,OPPS APC
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,170.171,686,other,OPPS APC
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,170.171,686,other,OPPS APC
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,183.192,686,other,OPPS APC
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,93.841,686,other,OPPS APC
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.8815,686,other,OPPS APC
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,686,other,OPPS APC
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,66.2275,416.02,other,OPPS APC
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,100.127,479.602522,other,OPPS APC
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,163,710.4,other,OPPS APC
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,88.004,416.02,other,OPPS APC
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,88.004,416.02,other,OPPS APC
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,40.859,416.02,other,OPPS APC
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,232.78851,,,232.78851,59.92,416.02,other,OPPS APC
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,98.67,479.602522,other,OPPS APC
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,66.2275,416.02,other,OPPS APC
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,59.4925,416.02,other,OPPS APC
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.123,416.02,other,OPPS APC
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.205,416.02,,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,43.553,416.02,other,OPPS APC
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,43.553,416.02,,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,22.74,416.02,other,OPPS APC
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,370.2005,1266.432,other,OPPS APC
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,355.8325,1217.28,other,OPPS APC
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,355.8325,1217.28,other,OPPS APC
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,182.294,623.616,other,OPPS APC
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,215.071,735.744,other,OPPS APC
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,157.3745,538.368,other,OPPS APC
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,176.457,603.648,other,OPPS APC
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,151.5375,518.4,other,OPPS APC
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,151.5375,829.50194,other,OPPS APC
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.817,570,,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.817,570,,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,30.083,570,,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,30.083,570,,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.4295,570,,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.4295,570,,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,94.4,583.68,other,OPPS APC
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,94.4,570,other,OPPS APC
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,94.4,570,other,OPPS APC
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,197.3355,675.072,,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,156.252,534.528,,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,74.983,416.02,other,OPPS APC
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.9805,585.854902,other,OPPS APC
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,93.841,416.02,other,OPPS APC
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,29.634,585.854902,other,OPPS APC
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,41.0835,416.02,other,OPPS APC
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.4705,416.02,other,OPPS APC
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,16.16,416.02,other,OPPS APC
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,74.983,416.02,other,OPPS APC
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,69.3705,416.02,other,OPPS APC
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,23.5725,416.02,other,OPPS APC
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,68.0235,416.02,other,OPPS APC
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,49.839,416.02,other,OPPS APC
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,155.1295,530.688,other,OPPS APC
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,162.538,556.032,other,OPPS APC
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,41.9815,585.854902,other,OPPS APC
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,70.143083,517.481916,other,OPPS APC
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,147.4965,585.854902,other,OPPS APC
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,34.385146,416.02,other,OPPS APC
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.38,,,14.38,14.38,416.02,fee schedule,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,27.6135,416.02,fee schedule,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.73,,,14.73,14.73,416.02,fee schedule,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20.02,,,20.02,20.02,416.02,fee schedule,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.44,,,14.44,14.44,416.02,fee schedule,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.44,,,14.44,14.44,416.02,fee schedule,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.33,,,30.33,30.33,416.02,fee schedule,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.33,,,30.33,30.33,416.02,fee schedule,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34.85,,,34.85,25.8175,416.02,fee schedule,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34.85,,,34.85,25.8175,416.02,fee schedule,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.33,,,30.33,25.8175,416.02,fee schedule,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.89,,,27.89,27.89,416.02,fee schedule,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.89,,,27.89,27.89,416.02,fee schedule,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18.56,,,18.56,18.56,416.02,other,OPPS APC
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18.56,,,18.56,18.56,416.02,other,OPPS APC
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,103.7,,,103.7,58.37,416.02,fee schedule,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,103.7,,,103.7,58.37,416.02,fee schedule,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,103.7,,,103.7,58.37,416.02,fee schedule,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,72.14,,,72.14,51.8595,416.02,fee schedule,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,38.12,,,38.12,25.8175,416.02,fee schedule,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,33.86,,,33.86,25.8175,416.02,fee schedule,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,49.68,,,49.68,25.8175,416.02,fee schedule,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.33,,,43.33,23.348,416.02,fee schedule,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34.45,,,34.45,34.45,416.02,fee schedule,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.36,,,29.36,23.797,416.02,fee schedule,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16.66,,,16.66,11.674,416.02,other,OPPS APC
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.635,416.02,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,other,OPPS APC
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,other,OPPS APC
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,81.0445,416.02,,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,74.085,416.02,,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,70.044,416.02,other,OPPS APC
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,82.56,416.02,other,OPPS APC
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,126.37,473.871,other,OPPS APC
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,179.35,693.026,other,OPPS APC
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,146.954008,985.784,other,OPPS APC
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.1184,416.02,other,OPPS APC
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.1184,416.02,other,OPPS APC
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.1184,416.02,other,OPPS APC
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.2428,416.02,other,OPPS APC
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.2428,416.02,other,OPPS APC
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.2428,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,90.68,416.02,other,OPPS APC
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,90.68,416.02,other,OPPS APC
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.8415,416.02,other,OPPS APC
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.8415,416.02,other,OPPS APC
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,169.273,685.583,other,OPPS APC
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,169.273,685.583,other,OPPS APC
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,968.49734,,,968.49734,318.748996,2424.576,other,OPPS APC
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,968.49734,,,968.49734,318.748996,2424.576,other,OPPS APC
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,204.5195,699.648,,
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,204.5195,699.648,,
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31.31797,,,31.31797,31.31797,416.02,other,OPPS APC
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31.31797,,,31.31797,31.31797,416.02,other,OPPS APC
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,173.763,2998,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,36.1445,2998,,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,22389.354,other,OPPS APC
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.0075,2998,,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,1477.69344,other,OPPS APC
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.30904,416.02,,
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.850175,416.02,,
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.025285,416.02,other,OPPS APC
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.025285,416.02,other,OPPS APC
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.025285,416.02,other,OPPS APC
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.025285,416.02,other,OPPS APC
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.401765,416.02,,
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.401765,416.02,,
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.99,416.02,,
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.3553,416.02,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.3553,416.02,,
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.3553,416.02,,
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.23,416.02,,
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.98576,416.02,,
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.98576,416.02,,
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.94544,416.02,,
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.94544,416.02,,
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.94544,416.02,,
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.94544,416.02,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.121435,416.02,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.121435,416.02,,
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.692165,416.02,,
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.206745,416.02,other,OPPS APC
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.206745,416.02,other,OPPS APC
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04041,416.02,other,OPPS APC
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04041,416.02,other,OPPS APC
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04041,416.02,other,OPPS APC
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04041,416.02,other,OPPS APC
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.913715,416.02,other,OPPS APC
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.913715,416.02,other,OPPS APC
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.913715,416.02,other,OPPS APC
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.913715,416.02,other,OPPS APC
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.67604,416.02,,
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,416.02,other,OPPS APC
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,416.02,other,OPPS APC
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,416.02,other,OPPS APC
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.600005,416.02,,
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.600005,416.02,,
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.600005,416.02,,
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.087465,416.02,,
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.66833,416.02,,
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.66833,416.02,,
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.122795,416.02,,
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.122795,416.02,,
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.98009,416.02,,
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.21357,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.12,416.02,other,OPPS APC
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.994945,416.02,,
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,291.097925,929.69805,other,OPPS APC
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,72522.399,,
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,72522.399,,
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,247.50227,1378.95936,other,OPPS APC
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,247.50227,1378.95936,other,OPPS APC
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,247.50227,1378.95936,other,OPPS APC
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,144.095325,460.20645,,
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23012.49024,other,OPPS APC
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23012.49024,other,OPPS APC
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23012.49024,other,OPPS APC
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23012.49024,other,OPPS APC
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.06164,416.02,other,OPPS APC
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.06164,416.02,other,OPPS APC
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.06164,416.02,other,OPPS APC
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.06164,416.02,other,OPPS APC
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46419.072,other,OPPS APC
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46419.072,other,OPPS APC
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46419.072,other,OPPS APC
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46419.072,other,OPPS APC
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2621.49888,other,OPPS APC
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2621.49888,other,OPPS APC
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2621.49888,other,OPPS APC
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2621.49888,other,OPPS APC
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7592.15526,other,OPPS APC
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7592.15526,other,OPPS APC
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7592.15526,other,OPPS APC
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6381.888,,
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19676.26496,,,19676.26496,399.86,42246.08608,other,OPPS APC
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12724.19328,,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,170.294475,582.5664,,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.890315,416.02,,
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.890315,416.02,,
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.890315,416.02,,
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.890315,416.02,,
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1487.02215,,
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.86,1724.0184,other,OPPS APC
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1479.062,other,OPPS APC
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.86,2573.3136,other,OPPS APC
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,77.228,836,other,OPPS APC
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.8808895,,,0.8808895,0.71,921.95328,other,OPPS APC
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.4,836.83584,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,,,,,3.39,416.02,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.39,416.02,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,,,,,3.39,416.02,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.39,416.02,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.31,416.02,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.31,416.02,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.31,416.02,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.36,1148.18304,other,OPPS APC
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.36,1148.18304,other,OPPS APC
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5136.79872,other,OPPS APC
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5136.79872,other,OPPS APC
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5136.79872,other,OPPS APC
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,182.24,5164.04736,other,OPPS APC
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,182.24,5164.04736,other,OPPS APC
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,182.24,5164.04736,other,OPPS APC
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41430.25152,,
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41430.25152,,
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41430.25152,,
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41430.25152,,
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,177.26,5164.08576,other,OPPS APC
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,177.26,5164.08576,other,OPPS APC
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.39,18739.8144,,
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.39,18739.8144,,
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.39,18739.8144,,
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.39,18739.8144,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21.562892,,,21.562892,18.2,1865.41824,other,OPPS APC
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21.562892,,,21.562892,18.2,1865.41824,other,OPPS APC
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,25024.512,other,OPPS APC
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,26025.216,other,OPPS APC
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,26025.216,other,OPPS APC
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,26025.216,,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,26025.216,other,OPPS APC
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,185.6615,1592,,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,386.589,2141,other,OPPS APC
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.349,1592,other,OPPS APC
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.3685,416.02,other,OPPS APC
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12.01,,,12.01,12.01,416.02,other,OPPS APC
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.6745,6652,other,OPPS APC
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.6745,6652,other,OPPS APC
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,701.034545,,,701.034545,104.83,6652,other,OPPS APC
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,other,OPPS APC
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,49.7570835,,,49.7570835,43.27,2936.50176,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2101.412877,,,2101.412877,336.23,7116.76416,other,OPPS APC
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2101.412877,,,2101.412877,336.23,7116.76416,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.3013095,,,2.3013095,1.61,416.02,other,OPPS APC
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.3013095,,,2.3013095,1.61,416.02,other,OPPS APC
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,256.044451,,,256.044451,215.38,15801.64608,other,OPPS APC
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,256.044451,,,256.044451,215.38,15801.64608,other,OPPS APC
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,231.3509075,,,231.3509075,194.92,2044.28544,other,OPPS APC
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.278507,,,7.278507,5.51,1270.70976,other,OPPS APC
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98,4260,other,Status Indicator B on TOB 12x or 13x: Research Alt
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98,4260,other,Status Indicator B on TOB 12x or 13x: Research Alt
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.51,416.02,other,OPPS APC
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.51,416.02,other,OPPS APC
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.51,416.02,other,OPPS APC
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.51,416.02,other,OPPS APC
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.84689,416.02,,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12.749415,,,12.749415,11.13,416.02,other,OPPS APC
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26.7187875,,,26.7187875,23.33,974.33088,other,OPPS APC
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26.7187875,,,26.7187875,23.33,974.33088,other,OPPS APC
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.82,416.02,other,OPPS APC
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.82,416.02,other,OPPS APC
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.82,416.02,other,OPPS APC
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.82,416.02,other,OPPS APC
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.38,416.02,other,OPPS APC
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,62.0276795,,,62.0276795,50.93,4488.66816,other,OPPS APC
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,62.0276795,,,62.0276795,50.93,4488.66816,other,OPPS APC
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.23144,416.02,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.23144,416.02,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.23144,416.02,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22.3635965,,,22.3635965,15.67,697.86624,other,OPPS APC
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22.3635965,,,22.3635965,15.67,697.86624,other,OPPS APC
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.338073,,,7.338073,6.15,1343.87712,other,OPPS APC
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.03,416.02,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.03,416.02,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.06,416.02,other,OPPS APC
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.06,416.02,other,OPPS APC
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6971.878415,,,6971.878415,60.43,12645.75744,other,OPPS APC
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6971.878415,,,6971.878415,60.43,12645.75744,other,OPPS APC
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0446745,,,0.0446745,0.04,416.02,other,OPPS APC
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0446745,,,0.0446745,0.04,416.02,other,OPPS APC
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.100804,,,0.100804,0.08,416.02,other,OPPS APC
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1343.739085,,,1343.739085,399.86,2155.44576,other,OPPS APC
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1343.739085,,,1343.739085,399.86,2155.44576,other,OPPS APC
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.68951,416.02,other,OPPS APC
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.68951,416.02,other,OPPS APC
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.68951,416.02,other,OPPS APC
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.44333,,,1.44333,1.22,416.02,other,OPPS APC
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.44333,,,1.44333,1.22,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9.427465,,,9.427465,7.54,500.98176,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.96,416.02,other,OPPS APC
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.96,416.02,other,OPPS APC
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.65,416.02,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,115.216681,,,115.216681,92.48,1248.58368,other,OPPS APC
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,115.216681,,,115.216681,92.48,1248.58368,other,OPPS APC
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.15189,416.02,other,OPPS APC
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.15189,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.74271,416.02,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.74271,416.02,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.74271,416.02,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.86,416.02,other,OPPS APC
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.86,416.02,other,OPPS APC
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.86,416.02,other,OPPS APC
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.40333,416.02,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.61749,416.02,other,OPPS APC
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.61749,416.02,other,OPPS APC
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.61749,416.02,other,OPPS APC
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17.883546,,,17.883546,14.7,4668.927562,other,OPPS APC
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.03,416.02,other,OPPS APC
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.03,416.02,other,OPPS APC
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.03,416.02,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.808809,,,4.808809,0.46,416.02,other,OPPS APC
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.808809,,,4.808809,0.46,416.02,other,OPPS APC
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.63,416.02,other,OPPS APC
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.78,416.02,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.78,416.02,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.88268,,,30.88268,24.19,6805.34016,other,OPPS APC
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.88268,,,30.88268,24.19,6805.34016,other,OPPS APC
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.03,416.02,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.295505,416.02,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.295505,416.02,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.295505,416.02,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.29108,416.02,other,OPPS APC
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.29108,416.02,other,OPPS APC
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.29108,416.02,other,OPPS APC
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.28219,416.02,other,OPPS APC
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.28219,416.02,other,OPPS APC
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.28219,416.02,other,OPPS APC
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5599.323132,,,5599.323132,399.86,9367.9104,other,OPPS APC
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,100.224377,,,100.224377,87.49,442.10688,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.3402,416.02,,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,820.0645955,,,820.0645955,399.86,1422.7584,other,OPPS APC
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.763505,945.2928,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.763505,945.2928,,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.763505,945.2928,,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.763505,945.2928,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.78,416.02,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.78,416.02,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.3171015,,,257.3171015,224.63,13826.65728,other,OPPS APC
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.86,416.02,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,74.8916445,,,74.8916445,52.988735,416.02,other,OPPS APC
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,74.8916445,,,74.8916445,52.988735,416.02,other,OPPS APC
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,438.481363,,,438.481363,339.74932,1162.26048,other,OPPS APC
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.2611955,,,1.2611955,1.1,1903.32672,other,OPPS APC
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.3781655,,,7.3781655,7.3781655,1590,other,OPPS APC
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.3781655,,,7.3781655,7.3781655,1590,other,OPPS APC
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,1056.72192,other,OPPS APC
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,1056.72192,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,57.105466,,,57.105466,48.47,416.02,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,57.105466,,,57.105466,48.47,416.02,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.1237725,,,56.1237725,44.12,1447.31904,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.1237725,,,56.1237725,44.12,1447.31904,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,36.41,416.02,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.28,416.02,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.28,416.02,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,666.4255535,,,666.4255535,333.276985,1140.11904,other,OPPS APC
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,666.4255535,,,666.4255535,333.276985,1140.11904,other,OPPS APC
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.56878,416.02,other,OPPS APC
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.56878,416.02,other,OPPS APC
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.56878,416.02,other,OPPS APC
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.56878,416.02,other,OPPS APC
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,27.14,416.02,other,OPPS APC
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,276.5271365,,,276.5271365,85.36837,416.02,other,OPPS APC
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.9114465,,,36.9114465,32.22,2399.94624,other,OPPS APC
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20.2398395,,,20.2398395,17.18,416.02,other,OPPS APC
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20.2398395,,,20.2398395,17.18,416.02,other,OPPS APC
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21,416.02,other,OPPS APC
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21,416.02,other,OPPS APC
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21,416.02,other,OPPS APC
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21,416.02,other,OPPS APC
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.83,416.02,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.83,416.02,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.410089,,,0.410089,0.36,416.02,other,OPPS APC
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.410089,,,0.410089,0.36,416.02,other,OPPS APC
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,114.43,1432.33536,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,114.43,1432.33536,,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.12259,,,1.12259,1,1207.54176,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8683105,,,1.8683105,1.24,416.02,other,OPPS APC
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8683105,,,1.8683105,1.24,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1853.014639,,,1853.014639,399.86,10964.15232,other,OPPS APC
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1853.014639,,,1853.014639,399.86,10964.15232,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.30786,416.02,other,OPPS APC
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.30786,416.02,other,OPPS APC
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34.8632925,,,34.8632925,29.75,6255.52128,other,OPPS APC
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.18518,416.02,other,OPPS APC
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.18518,416.02,other,OPPS APC
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.18518,416.02,other,OPPS APC
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.18518,416.02,other,OPPS APC
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.07677,,,1.07677,1.07677,506.21952,other,OPPS APC
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.18,416.02,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.18,416.02,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.41,416.02,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.41,416.02,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.41,416.02,,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.41,416.02,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.46,1022.48448,other,OPPS APC
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.46,1022.48448,other,OPPS APC
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.46,1022.48448,other,OPPS APC
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.46,1022.48448,other,OPPS APC
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.72,416.02,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.72,416.02,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.317135,416.02,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.317135,416.02,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.54,416.02,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.54,416.02,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.263845,416.02,other,OPPS APC
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.263845,416.02,other,OPPS APC
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3988.807407,,,3988.807407,399.86,45671.09376,other,OPPS APC
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.01,416.02,other,OPPS APC
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.01,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.739875,416.02,other,OPPS APC
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.739875,416.02,other,OPPS APC
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.89655,416.02,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.89655,416.02,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.89655,416.02,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.89655,416.02,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.20861,,,6.20861,5.42,416.02,other,OPPS APC
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.20861,,,6.20861,5.42,416.02,other,OPPS APC
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.40469,416.02,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.586535,416.02,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.586535,416.02,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.43,416.02,other,OPPS APC
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.43,416.02,other,OPPS APC
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.95,416.02,other,OPPS APC
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.95,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.136465,,,7.136465,7.136465,1471.59552,other,OPPS APC
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.136465,,,7.136465,7.136465,1471.59552,other,OPPS APC
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,425.3161315,,,425.3161315,357.36,11800.75008,other,OPPS APC
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,425.3161315,,,425.3161315,357.36,11800.75008,other,OPPS APC
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.88,455.8464,other,OPPS APC
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.88,455.8464,other,OPPS APC
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.88,455.8464,other,OPPS APC
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,,,other,OPPS APC
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,,,other,OPPS APC
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,,,other,OPPS APC
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39.331888,,,39.331888,33.71,3005.13792,other,OPPS APC
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39.331888,,,39.331888,33.71,3005.13792,other,OPPS APC
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12.9430045,,,12.9430045,10.7,2359.38048,other,OPPS APC
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12.9430045,,,12.9430045,10.7,2359.38048,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC
ROMIPLOSTIM 125 MCG SC SOLR|DISCARDED DRUG NOT ADMINISTERED,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,179.925976,,,179.925976,139.22,12730.14528,other,OPPS APC
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,179.925976,,,179.925976,139.22,12730.14528,other,OPPS APC
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.12,416.02,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.12,416.02,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.12,416.02,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.12,416.02,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.57,416.02,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,180.672842,,,180.672842,152.7,14884.48512,other,OPPS APC
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.358225,416.02,other,OPPS APC
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.358225,416.02,other,OPPS APC
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.358225,416.02,other,OPPS APC
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.358225,416.02,other,OPPS APC
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.63291,416.02,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.63291,416.02,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.63291,416.02,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.63291,416.02,,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2375.012116,,,2375.012116,399.86,4191.12192,other,OPPS APC
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52,416.02,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,44.72489,416.02,,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.9,416.02,other,OPPS APC
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.9,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25.49883,,,25.49883,22.26,18370.38336,other,OPPS APC
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.41,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.528165,416.02,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.528165,416.02,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.15,416.02,other,OPPS APC
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.15,416.02,other,OPPS APC
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.15,416.02,other,OPPS APC
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.15,416.02,other,OPPS APC
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5.7653015,,,5.7653015,5.69,1897.8816,other,OPPS APC
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.36,416.02,other,OPPS APC
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.36,416.02,other,OPPS APC
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.36,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.51,416.02,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.51,416.02,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.43,416.02,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.43,416.02,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.47,416.02,other,OPPS APC
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.47,416.02,other,OPPS APC
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.47,416.02,other,OPPS APC
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10347.43296,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.54,416.02,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.54,416.02,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.14,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.62,416.02,other,OPPS APC
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.23,416.02,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.23,416.02,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.39,416.02,other,OPPS APC
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.39,416.02,other,OPPS APC
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.39,416.02,other,OPPS APC
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.39,416.02,other,OPPS APC
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.89986,416.02,,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.568211,,,2.568211,2.568211,4642.0992,other,OPPS APC
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.568211,,,2.568211,2.568211,4642.0992,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.46624,,,1.46624,1.26,2225.664,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.46624,,,1.46624,1.26,2225.664,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.773234,,,1.773234,1.25,2861.568,other,OPPS APC
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.773234,,,1.773234,1.25,2861.568,other,OPPS APC
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.4136115,,,4.4136115,3.35,3804.8256,other,OPPS APC
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.4136115,,,4.4136115,3.35,3804.8256,other,OPPS APC
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.685052,,,2.685052,1.94,10651.392,other,OPPS APC
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,73.22,786.36288,other,OPPS APC
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.536555,416.02,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.536555,416.02,,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.32,416.02,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.5922235,,,0.5922235,0.52,416.02,other,OPPS APC
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.5922235,,,0.5922235,0.52,416.02,other,OPPS APC
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,other,OPPS APC
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,other,OPPS APC
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,87.818612,,,87.818612,69.53663,416.02,other,OPPS APC
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,87.818612,,,87.818612,69.53663,416.02,other,OPPS APC
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.2464545,,,8.2464545,7.2,2367.72096,other,OPPS APC
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.2464545,,,8.2464545,7.2,2367.72096,other,OPPS APC
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.32,416.02,other,OPPS APC
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.32,416.02,other,OPPS APC
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.2212105,,,6.2212105,5.43,2152.77312,other,OPPS APC
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.2212105,,,6.2212105,5.43,2152.77312,other,OPPS APC
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.829643,,,14.829643,12.95,3900.27264,other,OPPS APC
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,83.282432,,,83.282432,72.7,7001.856,other,OPPS APC
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,83.282432,,,83.282432,72.7,7001.856,other,OPPS APC
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.931495,416.02,other,OPPS APC
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.931495,416.02,other,OPPS APC
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.800726,,,1.800726,1.57,905.322979,other,OPPS APC
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.800726,,,1.800726,1.57,905.322979,other,OPPS APC
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,274.755048,,,274.755048,221.96,24824.61696,other,OPPS APC
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,247.9492025,,,247.9492025,206.03,30463.31136,other,OPPS APC
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.41,416.02,other,OPPS APC
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.41,416.02,other,OPPS APC
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.7904535,,,56.7904535,47.04,6870.26688,other,OPPS APC
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,86.4611945,,,86.4611945,72.08,3359.0784,other,OPPS APC
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,86.4611945,,,86.4611945,72.08,3359.0784,other,OPPS APC
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.37,416.02,other,OPPS APC
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16.3176475,,,16.3176475,14.25,416.02,other,OPPS APC
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.69078,416.02,other,OPPS APC
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.69078,416.02,other,OPPS APC
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.783608,,,4.783608,4.18,1339.56096,other,OPPS APC
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.783608,,,4.783608,4.18,1339.56096,other,OPPS APC
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.34,416.02,,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,155.5417175,,,155.5417175,128.78,3097.0368,other,OPPS APC
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,other,OPPS APC
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,other,OPPS APC
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,153.673407,,,153.673407,62.498555,604.75,other,OPPS APC
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.83,416.02,other,OPPS APC
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.83,416.02,other,OPPS APC
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.83,416.02,other,OPPS APC
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.79,416.02,other,OPPS APC
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.79,416.02,other,OPPS APC
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.79,416.02,other,OPPS APC
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.79,416.02,other,OPPS APC
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,772.951326,,,772.951326,399.86,5828.5824,other,OPPS APC
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,772.951326,,,772.951326,399.86,5828.5824,other,OPPS APC
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,416.02,other,OPPS APC
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,416.02,other,OPPS APC
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,416.02,other,OPPS APC
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,153.5622935,,,153.5622935,122.55,12759.31392,other,OPPS APC
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,153.5622935,,,153.5622935,122.55,12759.31392,other,OPPS APC
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.67,416.02,other,OPPS APC
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.67,416.02,other,OPPS APC
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,27.33512,416.02,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.620622,,,202.620622,167.93,74965.60128,other,OPPS APC
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.620622,,,202.620622,167.93,74965.60128,other,OPPS APC
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.47721,416.02,other,OPPS APC
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.47721,416.02,other,OPPS APC
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,83.0796785,,,83.0796785,72.53,1721.82528,other,OPPS APC
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15.285552,,,15.285552,12.06,3366.45888,other,OPPS APC
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2911.602117,,,2911.602117,399.86,4898.21952,other,OPPS APC
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.686428,,,66.686428,54.81,12451.14624,other,OPPS APC
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,62.6027205,,,62.6027205,29.06,416.02,other,OPPS APC
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,85.440554,,,85.440554,70.55,18103.04256,other,OPPS APC
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,182.507933,,,182.507933,149.71,14042.8032,other,OPPS APC
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,182.507933,,,182.507933,149.71,14042.8032,other,OPPS APC
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.792772,,,4.792772,4.18,8613.9648,other,OPPS APC
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.792772,,,4.792772,4.18,8613.9648,other,OPPS APC
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18.463169,,,18.463169,15.37,14335.95648,other,OPPS APC
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,428.151244,,,428.151244,356.51,15644.98176,other,OPPS APC
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,81.4118305,,,81.4118305,68.87,15685.39392,other,OPPS APC
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,81.4118305,,,81.4118305,68.87,15685.39392,other,OPPS APC
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,88.563187,,,88.563187,77.31,10318.18752,other,OPPS APC
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,88.563187,,,88.563187,77.31,10318.18752,other,OPPS APC
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,424.045772,,,424.045772,223.44,900.08832,other,OPPS APC
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.896555,,,36.896555,32.21,4261.85472,other,OPPS APC
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,other,OPPS APC
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,46.3297475,,,46.3297475,38.33,13677.02016,other,OPPS APC
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,46.3297475,,,46.3297475,38.33,13677.02016,other,OPPS APC
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,89.28027,,,89.28027,77.94,3651.07968,other,OPPS APC
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,89.28027,,,89.28027,77.94,3651.07968,other,OPPS APC
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.95,416.02,other,OPPS APC
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.49,416.02,other,OPPS APC
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.49,416.02,other,OPPS APC
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.59,416.02,other,OPPS APC
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7115,,,60.7115,1.65,1060,other,OPPS APC
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7115,,,60.7115,1.65,1060,other,OPPS APC
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.2,,,29.2,4.41367,416.02,other,OPPS APC
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.2,,,29.2,4.41367,416.02,other,OPPS APC
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.2,,,29.2,4.41367,416.02,other,OPPS APC
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.2,,,29.2,4.41367,416.02,other,OPPS APC
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.34,,,873.34,110.03643,1222.676,fee schedule,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.34,,,873.34,110.03643,1222.676,fee schedule,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.34,,,873.34,110.03643,1222.676,fee schedule,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,101.16,,,101.16,23.579235,416.02,other,OPPS APC
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,101.16,,,101.16,23.579235,416.02,other,OPPS APC
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,101.16,,,101.16,23.579235,416.02,other,OPPS APC
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,101.16,,,101.16,23.579235,416.02,other,OPPS APC
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,185.48,,,185.48,16.49177,416.02,other,OPPS APC
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,185.48,,,185.48,16.49177,416.02,other,OPPS APC
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,185.48,,,185.48,16.49177,416.02,other,OPPS APC
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,261.35,,,261.35,31.76675,416.02,other,OPPS APC
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,261.35,,,261.35,31.76675,416.02,other,OPPS APC
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,261.35,,,261.35,31.76675,416.02,other,OPPS APC
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,261.35,,,261.35,31.76675,416.02,other,OPPS APC
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,335.72,,,335.72,335.72,5377.9968,fee schedule,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.86,,,124.86,15.326615,416.02,other,OPPS APC
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.86,,,124.86,15.326615,416.02,other,OPPS APC
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.86,,,124.86,15.326615,416.02,other,OPPS APC
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.18,,,56.18,17.225885,416.02,other,OPPS APC
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.18,,,56.18,17.225885,416.02,other,OPPS APC
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.18,,,56.18,17.225885,416.02,other,OPPS APC
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20.61,,,20.61,20.61,416.02,other,OPPS APC
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,125.65,,,125.65,125.65,1058.40384,other,OPPS APC
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,125.65,,,125.65,125.65,1058.40384,other,OPPS APC
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3409.78176,,
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,252.25,3748.3008,other,OPPS APC
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,252.25,3748.3008,other,OPPS APC
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.737705,686.06,,
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3534.81216,other,OPPS APC
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3534.81216,other,OPPS APC
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,401.49775,,,401.49775,326.6475,1117.44,other,OPPS APC
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,68.581085,,,68.581085,49.4,942.336,other,OPPS APC
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,207.12931,,,207.12931,123.6995,423.168,other,OPPS APC
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,91.59418,,,91.59418,71.53,416.02,other,OPPS APC
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,156.372205,,,156.372205,105.7395,416.02,other,OPPS APC
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,454.90096,,,454.90096,163,871.3328,other,OPPS APC
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,149.92304,,,149.92304,136.61,1072.896,other,OPPS APC
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,264.186665,,,264.186665,163,1384.1308,other,OPPS APC
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,541.054015,,,541.054015,163,1119.53,other,OPPS APC
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,770.32584,,,770.32584,163,1476.21,other,OPPS APC
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,356.376505,,,356.376505,163,2191.8936,other,OPPS APC
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,289.21584,,,289.21584,142.782,598.2,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,825.527485,,,825.527485,163,1698,other,OPPS APC
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,564.38785,,,564.38785,163,1747.7512,other,OPPS APC
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,277.05063,,,277.05063,163,1046.786,other,OPPS APC
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,83.128935,,,83.128935,49.839,416.02,other,OPPS APC
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,631.49124,,,631.49124,163,1265.41,other,OPPS APC
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,19.9805,416.02,other,OPPS APC
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.387179,,,0.387179,0.34,726.30528,other,OPPS APC
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,416.02,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,416.02,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,152.44314,,,152.44314,87.98,1653.428703,other,OPPS APC
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,152.44314,,,152.44314,87.98,1653.428703,other,OPPS APC
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,348.861775,3862.93248,other,OPPS APC
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,348.861775,3862.93248,other,OPPS APC
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,348.861775,3862.93248,other,OPPS APC
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,348.861775,3862.93248,other,OPPS APC
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,30.42,6716.16,,
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.25,659.42016,,
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.25,659.42016,,
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.96,24594.91584,other,OPPS APC
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.96,24594.91584,other,OPPS APC
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.96,24594.91584,other,OPPS APC
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,8051.0208,other,OPPS APC
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,8051.0208,other,OPPS APC
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,8051.0208,other,OPPS APC
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,46.98,6518.784,other,OPPS APC
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.16,4034.304,,
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.16,4034.304,,
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.4745,3643.99872,other,OPPS APC
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.4745,3643.99872,other,OPPS APC
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.4745,3643.99872,other,OPPS APC
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.4745,3643.99872,other,OPPS APC
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,102.28,3422.3616,other,OPPS APC
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,102.28,3422.3616,other,OPPS APC
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15.599419,,,15.599419,13.62,1653.428703,other,OPPS APC
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31.136981,,,31.136981,27.18,1653.428703,other,OPPS APC
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31.136981,,,31.136981,27.18,1653.428703,other,OPPS APC
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,38.481927,,,38.481927,33.59,7269.974281,other,OPPS APC
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,38.481927,,,38.481927,33.59,7269.974281,other,OPPS APC
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,24.387695,,,24.387695,21.29,1590.89664,other,OPPS APC
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.92,438.4896,other,OPPS APC
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.92,438.4896,other,OPPS APC
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.56,416.02,other,OPPS APC
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.56,416.02,other,OPPS APC
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.38,416.02,other,OPPS APC
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.38,416.02,other,OPPS APC
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.38,416.02,other,OPPS APC
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.38,416.02,other,OPPS APC
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9.775697,,,9.775697,9.53,2181.7344,other,OPPS APC
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9.775697,,,9.775697,9.53,2181.7344,other,OPPS APC
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3992.7552,other,OPPS APC
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3992.7552,other,OPPS APC
Bilateral procedure,,,,,,,,,,,,,,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,525.9295,1261.6,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,808.0705,1938.4,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,731.3655,1754.4,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1108.2205,2658.4,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,955.5,,,955.5,594.6305,2483,per diem,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,444.5555,1066.4,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,398.5325,956,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1337.0015,3207.2,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1215.941,2916.8,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,672.0025,1612,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1604.135,3848,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,72,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.491,94.4,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.3685,90.4,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.96,64,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.7355,63.2,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,59.9415,213.6,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,72,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.309,225.6,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.166,214.4,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.5335,226.4,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.9825,228,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,64.4315,229.6,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.9215,245.6,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.9635,338.4,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,98.331,350.4,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,423.2,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,423.2,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,183.192,652.8,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,871.958,3107.2,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1098.0295,3912.8,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1176.829,4193.6,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1227.117,4372.8,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,149.7415,533.6,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.2485,282.4,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,73.4115,261.6,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,87.555,312,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,158.7215,565.6,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,32.328,122.0544,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,58.819,222.0712,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,61.064,230.5472,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.697,259.3656,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,84.6365,319.5452,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,105.7395,399.2196,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,110.005,415.324,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,210.8055,795.8964,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.756,74.5888,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.3275,80.522,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.246,91.5408,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,28.736,108.4928,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,43.3285,163.5868,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,43.7775,165.282,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,50.5125,190.71,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.1465,302.5932,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.1465,302.5932,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.1465,302.5932,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,83.963,317.0024,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,88.902,335.6496,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,90.249,340.7352,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,91.8205,346.6684,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,93.841,354.2968,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,93.6165,353.4492,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.127,378.0296,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,101.2495,382.2676,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,104.617,394.9816,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,104.617,394.9816,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,105.515,398.372,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.556,413.6288,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,115.842,437.3616,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,116.5155,439.9044,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,117.4135,443.2948,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,121.4545,458.5516,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,121.4545,458.5516,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,124.822,471.2656,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,151.313,571.2824,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.803,588.2344,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.803,588.2344,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.803,588.2344,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.8235,595.8628,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,161.4155,609.4244,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,162.089,611.9672,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,164.1095,619.5956,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,171.7425,648.414,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.212,657.7376,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.212,657.7376,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,189.7025,716.222,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,189.7025,716.222,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,189.7025,716.222,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.9275,758.602,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.9275,758.602,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,185.6615,700.9652,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,210.8055,795.8964,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,219.7855,829.8004,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,354.9345,1340.0556,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,354.9345,1340.0556,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,255.032,962.8736,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,284.8905,1075.6044,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,296.1155,1117.9844,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,314.0755,1185.7924,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,316.096,1193.4208,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,455.0615,1718.0852,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,498.1655,1880.8244,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,584.149,2205.4552,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,660.7035,2494.4868,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1249.3425,4716.894,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1237.444,4671.9712,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,924.94,3492.112,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1237.444,4671.9712,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,302.8505,1143.4124,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.7555,33.0564,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,277.931,1049.3288,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,249.8685,943.3788,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,423.6315,1599.4212,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,246.2765,929.8172,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,337.648,1274.7904,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,71.6155,270.3844,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,103.719,391.5912,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,241.7865,912.8652,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.107,411.9336,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.3515,378.8772,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,299.034,1129.0032,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,66.6765,251.7372,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,120.5565,455.1612,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,126.8425,478.894,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,93.6165,353.4492,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,92.494,349.2112,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.1295,585.6916,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,113.597,428.8856,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,95.188,359.3824,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,133.353,503.4744,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,448.3804,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,203.397,767.9256,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.476,549.2448,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,222.255,839.124,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,194.1925,733.174,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,97.2085,367.0108,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,88.453,333.9544,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,136.047,513.6456,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.15,593.32,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,495.0225,1868.958,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,299.932,1132.3936,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,245.603,927.2744,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,266.706,1006.9488,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,259.073,978.1304,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,259.073,978.1304,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,176.2325,665.366,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.8855,660.2804,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,267.3795,1009.4916,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,220.6835,833.1908,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,102.5965,387.3532,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,105.7395,399.2196,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,104.3925,394.134,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,184.7635,697.5748,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,138.9655,524.6644,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,178.4775,673.842,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,162.089,611.9672,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,55.0025,207.662,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,214.173,808.6104,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,259.073,978.1304,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,111.5765,421.2572,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,56.3495,212.7476,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,91.596,345.8208,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.3515,378.8772,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.5955,304.2884,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.044,264.4512,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.044,264.4512,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,139.639,527.2072,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,123.924,467.8752,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,274.1145,1034.9196,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,846.814,3197.1472,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,438.673,1656.2104,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,854.447,3225.9656,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,148.3945,560.2636,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.965,483.132,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.965,483.132,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,759.9325,2869.126,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,715.0325,2699.606,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,85.31,322.088,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.8855,660.2804,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,74.085,279.708,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,85.759,323.7832,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.576,379.7248,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.1885,400.9148,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.699,425.4952,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,147.721,557.7208,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,148.3945,560.2636,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.8235,595.8628,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,167.2525,631.462,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,176.2325,665.366,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,202.2745,763.6876,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,205.4175,775.554,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,250.7665,946.7692,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,574.72,2169.856,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,574.72,2169.856,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,667.663,2520.7624,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,675.9695,2552.1236,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,675.9695,2552.1236,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,710.5425,2682.654,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,767.341,2897.0968,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,777.219,2934.3912,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1481.0265,5591.6172,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,147.721,557.7208,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,147.721,557.7208,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,276.584,1044.2432,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,392.875,1483.3,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,882.9585,3333.6108,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,923.593,3487.0264,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1001.4945,3781.1436,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,104.617,394.9816,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,667.663,2520.7624,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,667.663,2520.7624,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,667.663,2520.7624,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,238.419,900.1512,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,238.419,900.1512,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,238.419,900.1512,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,324.4025,1224.782,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.576,379.7248,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,77.9015,294.1172,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,239.0925,902.694,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.2485,299.2028,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,317.2185,1197.6588,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,289.605,1093.404,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,289.605,1093.404,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,479.3075,1809.626,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,167.2525,631.462,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,58.819,222.0712,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,58.819,222.0712,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.2485,299.2028,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,288.707,1090.0136,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.7005,550.0924,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,170.171,642.4808,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,238.6435,900.9988,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,245.3785,926.4268,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,273.2165,1031.5292,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,304.1975,1148.498,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,313.851,1184.9448,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,330.913,1249.3624,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,336.5255,1270.5524,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,398.0385,1502.7948,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,355.8325,1343.446,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,367.282,1386.6736,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,392.6505,1482.4524,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.413,401.7624,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.413,401.7624,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.413,401.7624,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,73.636,278.0128,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.107,411.9336,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,398.0385,1502.7948,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.803,588.2344,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.413,401.7624,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.6375,402.61,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,383.895,1449.396,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,297.9115,1124.7652,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,297.9115,1124.7652,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,291.85,1101.88,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.184,27.1232,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.879,120.3592,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,35.2465,133.0732,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,34.124,128.8352,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,46.696,176.3008,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.47,50.856,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.8375,63.57,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.47,50.856,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.8375,63.57,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2255,83.9124,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.43,118.664,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,30.981,116.9688,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,35.6955,134.7684,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.15,593.32,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,190.825,720.46,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,373.119,1408.7112,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,213.275,805.22,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,656.438,2478.3824,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,269.4,1017.12,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,956.819,3612.4712,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2057.767,7769.1016,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,269.4,1017.12,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,841.6505,3177.6524,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1202.422,4539.7456,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2164.4045,8171.7116,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.6125,21.19,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.939,18.6472,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.1635,19.4948,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.286,23.7328,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.5105,24.5804,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.4085,27.9708,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.531,32.2088,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,336.75,1271.4,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.6745,6652,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.7405,482.2844,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.7405,482.2844,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.5105,24.5804,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.5715,163,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.6535,163,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,38.3895,163,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9291.52,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6297.984,,
Heart Transplant Or Implant Of Heart Assist System With McC,1,MS-DRG,,,,,,,inpatient,,,509415.58,356590.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,570763.9296,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,495073.43,346551.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,434261.5728,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,347238.19,243066.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,286312.0824,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,111379.6,77965.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,109336.4384,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,80508.95,56356.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,90620.608,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,64638.3,45246.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,123186.8824,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,31748.36,22223.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,68016.116,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,38853.43,27197.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45091.4528,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,36305.14,25413.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32329.1856,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,66447.77,46513.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,78796.564,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,67076.27,46953.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,53661.016,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,60360.78,42252.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48288.624,,
Extracranial Procedures With McC,37,MS-DRG,,,,,,,inpatient,,,89958.63,62971.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71966.904,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,41578.78,29105.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33263.024,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,33795.18,23656.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,27036.144,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,68215.86,47751.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,54572.688,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,26930.4,18851.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30377.7624,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,21358.75,14951.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7123.143125,22105.9976,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,44783.08,31348.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50741.056,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,47305.96,33114.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37844.768,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,15006.39,10504.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5004.631065,37401.2648,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,24159.04,16911.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,24793.004,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,28159.44,19711.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6624.72,22527.552,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,89978.5,62984.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71982.8,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,41764.16,29234.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36086.1312,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,42817.54,29972.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34254.032,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,29171.68,20420.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40307.1224,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20113.63,14079.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6707.895605,20608.488,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,15729.11,11010.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5143.64,13947.7112,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,46442.5,32509.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37154,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,28051.55,19636.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6429.37,22441.24,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17263.03,12084.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5687.74,16215.2528,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,34983.65,24488.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35233.0168,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,19683.37,13778.359,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6564.403895,21354.2032,,
Nonspecific Cerebrovascular Disorders Without Cc/McC,72,MS-DRG,,,,,,,inpatient,,,12084.89,8459.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4030.310815,15200.0264,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,16388.09,11471.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5465.428015,31318.012,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,28055.14,19638.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7368.52,22444.112,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,26116.94,18281.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7097.19,20893.552,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,23235.5,16264.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7749.03925,31332.1968,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,15869.98,11108.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5292.63833,20219.4192,,
Hypertensive Encephalopathy Without Cc/McC,79,MS-DRG,,,,,,,inpatient,,,15211.5,10648.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5073.03525,13510.0088,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,53186.54,37230.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42549.232,,
Nontraumatic Stupor And Coma Without McC,81,MS-DRG,,,,,,,inpatient,,,72271.24,50589.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5585.72,57816.992,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,28572.47,20000.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47014.5064,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,30376.08,21263.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28173.0392,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,15324.04,10726.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5110.56734,19372.384,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,40898.43,28628.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45916.1976,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,13317.55,9322.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4441.402925,26578.2624,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,24255.02,16978.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6241.25,19404.016,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,42230.83,29561.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36937.2192,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,30155.68,21108.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7134.82,24124.544,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,16152.97,11307.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5387.015495,15994.3752,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,56481.63,39537.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,73931.1776,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,49973.83,34981.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,72642.3872,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,15617.77,10932.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5208.526295,43954.6424,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC,99,MS-DRG,,,,,,,inpatient,,,27081.74,18957.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28231.8048,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,34012.87,23809.009,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40228.0928,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,18803.33,13162.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6270.910555,18675.3024,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,27377.14,19163.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,23494.0816,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,23893.76,16725.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5992.35,19115.008,,
Acute Major Eye Infections With Cc/McC,121,MS-DRG,,,,,,,inpatient,,,20815.14,14570.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6941.84919,23569.0584,,
Acute Major Eye Infections Without Cc/McC,122,MS-DRG,,,,,,,inpatient,,,8234.57,5764.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2746.229095,13745.0712,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,28026.78,19618.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5537.24,22421.424,,
Other Disorders Of The Eye With McC Or Thrombolytic Agent,124,MS-DRG,,,,,,,inpatient,,,12298.33,8608.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4101.493055,26420.2032,,
Other Disorders Of The Eye Without McC,125,MS-DRG,,,,,,,inpatient,,,18740.93,13118.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6044.44,16731.9848,,
Mouth Procedures With Cc/McC,137,MS-DRG,,,,,,,inpatient,,,29533.69,20673.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28339.204,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,44941.05,31458.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,66905.6488,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,9316.44,6521.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3107.03274,35595.7424,,
Ear- Nose- Mouth And Throat Malignancy With McC,146,MS-DRG,,,,,,,inpatient,,,13156.92,9209.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4387.83282,46483.5896,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,13619.01,9533.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4541.939835,15147.34,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,14296.01,10007.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4767.719335,15360.112,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,12866.36,9006.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4290.93106,22993.5608,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,16420.88,11494.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5141.47,14421.8888,,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,12009,8406.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4005.0015,32953.3168,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,39912.51,27938.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6561.05,31930.008,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,11067.63,7747.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3691.054605,13625.5136,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,32953.66,23067.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33180.2736,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,27223.03,19056.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6432.99,21778.424,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,2839.79,1987.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,947.069965,13366.1344,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,115551.53,80886.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,93394.7496,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,85038.13,59526.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,68030.504,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,69826.08,48878.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,55860.864,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,55683.12,38978.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,78036.664,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,45649.7,31954.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37024.3544,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,47015.57,32910.899,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37612.456,,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,78265.02,54785.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,62612.016,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,20842.72,14589.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6951.04712,28554.0024,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,18317.47,12822.229,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6108.876245,16505.028,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,31259.62,21881.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32756.756,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,20969.38,14678.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6993.28823,20103.9144,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20162.41,14113.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6302.75,16129.928,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,37050.11,25935.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35415.3928,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,30930.47,21651.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,24744.376,,
Respiratory Neoplasms Without Cc/McC,182,MS-DRG,,,,,,,inpatient,,,24638.57,17246.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5697.87,19710.856,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,35855.45,25098.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32163.0208,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,22588.59,15812.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7520.46,21641.952,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,25741.06,18018.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32017.12,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,11443.72,8010.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3816.48062,20343.0296,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,21611.05,15127.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7207.285175,25076.7,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,22710.76,15897.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7574.03846,22762.5512,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,17567.6,12297.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5858.7946,17408.8024,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,13024.23,9116.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4343.580705,13114.8608,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,25981.01,18186.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26703.8992,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,18230.9,12761.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6080.00515,16616.48,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,12094.06,8465.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4033.36901,12620.4192,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25422.94,17796.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38181.4288,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,23032.67,16122.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7275.91,20059.3336,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,22301.78,15611.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7437.64363,35770.0128,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,31940.04,22358.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25552.032,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,17352.2,12146.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5133.51,13881.76,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,17596.96,12317.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5868.58616,19589.2088,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,12229.54,8560.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4078.55159,14109.8232,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,30544.64,21381.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5734.05,24435.712,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,23745.99,16622.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38252.3528,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,17630.01,12341.007,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5879.608335,18355.1312,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,173078.09,121154.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,138462.472,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,53859.21,37701.447,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,54390.6024,,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,inpatient,,,221306.62,154914.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,220737.7784,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,354301.39,248010.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,283441.112,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC,216,MS-DRG,,,,,,,inpatient,,,299760.69,209832.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,239808.552,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,inpatient,,,204620.11,143234.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,163696.088,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC,219,MS-DRG,,,,,,,inpatient,,,208854.44,146198.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,167083.552,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,inpatient,,,154365.68,108055.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,123492.544,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,181781.45,127247.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,145425.16,,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,228758.84,160131.188,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,183007.072,,
Other Cardiothoracic Procedures Without McC,229,MS-DRG,,,,,,,inpatient,,,95347.28,66743.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,76277.824,,
Coronary Bypass With Ptca With McC,231,MS-DRG,,,,,,,inpatient,,,220697.29,154488.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,176557.832,,
Coronary Bypass With Ptca Without McC,232,MS-DRG,,,,,,,inpatient,,,203083.55,142158.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,162466.84,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,193515.4,135460.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,158379.3712,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,165546.93,115882.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,132437.544,,
Coronary Bypass Without Cardiac Catheterization With McC,235,MS-DRG,,,,,,,inpatient,,,145342.16,101739.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,119229.3232,,
Coronary Bypass Without Cardiac Catheterization Without McC,236,MS-DRG,,,,,,,inpatient,,,130227.12,91158.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,104181.696,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,39344.02,27540.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,102059.636,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,41409.42,28986.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59008.768,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC,241,MS-DRG,,,,,,,inpatient,,,19499.72,13649.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6503.15662,30594.5872,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,76706.54,53694.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,68735.488,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,63602.84,44521.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50882.272,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,60755.43,42528.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48604.344,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,109531.23,76671.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,99020.036,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC,250,MS-DRG,,,,,,,inpatient,,,42609.28,29826.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46864.5528,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,52812.94,36969.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42250.352,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,100566.7,70396.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,80453.36,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,72499.37,50749.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,57999.496,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,68903.94,48232.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,55123.152,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13134.86,9194.402,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4380.47581,34319.1104,,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,20863.13,14604.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6957.853855,18073.4616,,
Cardiac Pacemaker Device Replacement With McC,258,MS-DRG,,,,,,,inpatient,,,71596.9,50117.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,57277.52,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,44827.64,31379.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35862.112,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,130030.35,91021.245,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,104024.28,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,49670.67,34769.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39736.536,,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC,262,MS-DRG,,,,,,,inpatient,,,58341.51,40839.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46673.208,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,49042.27,34329.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,70820.6536,,
Aicd Lead Procedures,265,MS-DRG,,,,,,,inpatient,,,64208.05,44945.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,72279.6616,,
Endovascular Cardiac Valve Replacement And Supplement Procedures With McC,266,MS-DRG,,,,,,,inpatient,,,134751.65,94326.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,121389.4656,,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC,267,MS-DRG,,,,,,,inpatient,,,133213.57,93249.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,106697.816,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,241728.99,169210.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,193383.192,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,132639.05,92847.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,106111.24,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,135782.35,95047.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,108625.88,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,140000.81,98000.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,112000.648,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,151532.98,106073.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,121226.384,,
Percutaneous And Other Intracardiac Procedures With McC,273,MS-DRG,,,,,,,inpatient,,,102782.81,71947.967,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,82226.248,,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,82201.95,57541.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,65761.56,,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,183325.52,128327.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,146660.416,,
Cardiac Defibrillator Implant With McC,276,MS-DRG,,,,,,,inpatient,,,196887.28,137821.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,157509.824,,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,177791.04,124453.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,142232.832,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,157626.97,110338.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,126101.576,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,93744.91,65621.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,74995.928,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31041.23,21728.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33263.356,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,26543.44,18580.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6744.11,21234.752,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,23815.3,16670.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5249.28,19052.24,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,19212.47,13448.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6407.358745,39624.2256,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,10954.07,7667.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3653.182345,15013.5976,,
Acute Myocardial Infarction- Expired Without Cc/McC,285,MS-DRG,,,,,,,inpatient,,,7163.26,5014.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2388.94721,11374.1832,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,38892.53,27224.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44850.3112,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,30727.74,21509.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,24582.192,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,28457.96,19920.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,55347.0632,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,19767.12,13836.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6592.33452,31948.2224,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,20727.01,14508.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6912.457835,26442.4936,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,15225.15,10657.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5077.587525,17453.3832,,
Heart Failure And Shock Without Cc/McC,293,MS-DRG,,,,,,,inpatient,,,10124.22,7086.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3376.42737,11124.936,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,25950.27,18165.189,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33198.5112,,
Cardiac Arrest- Unexplained With Cc,297,MS-DRG,,,,,,,inpatient,,,10642.36,7449.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3549.22706,14273.9616,,
Cardiac Arrest- Unexplained Without Cc/McC,298,MS-DRG,,,,,,,inpatient,,,12953.57,9067.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4151.065639,10362.856,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,22073.95,15451.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7361.662325,32781.0728,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,21942.88,15360.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7317.95048,21692.612,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,24649.73,17254.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5372.28,19719.784,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,9953.04,6967.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3319.33884,23571.0848,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16791.27,11753.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4894.02,13625.5136,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,37676.15,26373.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30140.92,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,16488.7,11542.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5343.34,15212.1848,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,22172.6,15520.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7394.5621,30343.3136,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,15582.95,10908.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5196.913825,18770.5432,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,19410.63,13587.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6473.445105,24438.384,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,14290.45,10003.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4765.865075,14981.1752,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,11407.4,7985.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3804.3679,11337.708,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,11897.35,8328.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3967.766225,14154.404,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,16541.17,11578.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5516.480195,17656.0232,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,15084.64,10559.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5030.72744,14454.3112,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,31164.15,21814.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43636.4976,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,18201.8,12741.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6070.3003,19500.0472,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,10045.09,7031.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3350.037515,13832.2064,,
Other Endovascular Cardiac Valve Procedures With McC,319,MS-DRG,,,,,,,inpatient,,,92577.92,64804.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,89009.62,,
Other Endovascular Cardiac Valve Procedures Without McC,320,MS-DRG,,,,,,,inpatient,,,39673.91,27771.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46903.0544,,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,92249.33,64574.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,73799.464,,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,75877.65,53114.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,60702.12,,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,116736.51,81715.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,93389.208,,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,126333.04,88433.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,101066.432,,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,inpatient,,,98701.5,69091.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,78961.2,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,64991.97,45494.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,102914.7768,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,59110.49,41377.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,49203.0184,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,49561.22,34692.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39648.976,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,78913.19,55239.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,93046.2088,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,69586.46,48710.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,55669.168,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,57546.85,40282.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46037.48,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,97325,68127.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,77860,,
Rectal Resection Without Cc/McC,334,MS-DRG,,,,,,,inpatient,,,106215.45,74350.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,84972.36,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,73034.84,51124.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,73434.7096,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,43630.89,30541.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42805.6736,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,37370.19,26159.133,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31105.24,,
Minor Small And Large Bowel Procedures With McC,344,MS-DRG,,,,,,,inpatient,,,23852.76,16696.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,54599.3216,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,15908.61,11136.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5305.521435,30177.1488,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,21216.99,14851.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7075.866165,25232.7328,,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,44922.74,31445.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47956.7824,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,23475.59,16432.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25508.3232,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,34354.1,24047.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30491.2408,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,42230.08,29561.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33784.064,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,312395.2,218676.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,249916.16,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,44235.04,30964.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35388.032,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,51507.45,36055.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,41205.96,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,70735.47,49514.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,86434.0656,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,77577.93,54304.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,62062.344,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,27080.24,18956.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,27457.72,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,23431.55,16402.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33838.8536,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,31489.94,22042.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25191.952,,
Major Esophageal Disorders Without Cc/McC,370,MS-DRG,,,,,,,inpatient,,,29793.71,20855.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5409.18,23834.968,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,37215.27,26050.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35427.5512,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,24764.87,17335.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7435.09,20857.7352,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,19807.89,13865.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5379.51,15846.312,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,38795.7,27156.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42787.436,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,40108.1,28075.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32086.48,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,8031.54,5622.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2678.51859,17891.0856,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,38252.31,26776.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36841.9784,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,30659.48,21461.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7186.19,24527.584,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,17080.5,11956.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4609.67,13664.4,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33361.1,23352.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38994.0152,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,34876.59,24413.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7667.34,27901.272,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,23295.58,16306.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6456.86,18636.464,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,19010.83,13307.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6340.111805,32922.9208,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,17687.57,12381.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5898.804595,20109.9936,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12268.03,8587.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4091.388005,13582.9592,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,35037.99,24526.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29788.08,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,19193.48,13435.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5946.04,16245.6488,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12403.72,8682.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4136.64062,11086.4344,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,23697.98,16588.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26037.2136,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16680.62,11676.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5530.73,15811.9992,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,35226.46,24658.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33555.1576,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,21027.93,14719.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6791.14,19074.5032,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,19292.51,13504.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4700.83,15434.008,,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,31379.86,21965.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50206.0864,,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,37379.45,26165.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30665.5112,,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,31865.55,22305.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25492.44,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,43167.44,30217.208,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,56905.3648,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,37981.98,26587.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43275.7984,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC,408,MS-DRG,,,,,,,inpatient,,,66496.81,46547.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,70946.2904,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,54723.42,38306.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43778.736,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC,410,MS-DRG,,,,,,,inpatient,,,49332.9,34533.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39466.32,,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,inpatient,,,94854.82,66398.374,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,75883.856,,
Cholecystectomy Except By Laparoscope Without C.D.E. With McC,414,MS-DRG,,,,,,,inpatient,,,158479.92,110935.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,126783.936,,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/McC,416,MS-DRG,,,,,,,inpatient,,,36054.28,25237.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28843.424,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,57775.9,40443.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48157.396,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,45650.74,31955.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36520.592,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,40583.9,28408.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32467.12,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,43141.15,30198.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71515.7088,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,126455.95,88519.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,101164.76,,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,inpatient,,,66431.87,46502.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,53145.496,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,37750.2,26425.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39699.2024,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,22206.74,15544.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7405.94779,21676.4008,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,9888.24,6921.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3297.72804,14111.8496,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41222.48,28855.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36971.668,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,21857.06,15299.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7289.32951,22849.6864,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,34142.65,23899.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33715.2432,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,18774.77,13142.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6109.56,17431.0928,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,12926.06,9048.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4310.84101,12464.3864,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,33617.1,23531.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38305.0392,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,18826.25,13178.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6278.554375,19579.0768,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,9263.58,6484.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3089.40393,14237.4864,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,36248.92,25374.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34134.708,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,33226.4,23258.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26581.12,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,28308.58,19816.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5905.53,22646.864,,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,114168.82,79918.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,91335.056,,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,93512.08,65458.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,74809.664,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With McC,456,MS-DRG,,,,,,,inpatient,,,202351.8,141646.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,171607.7104,,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,152088.75,106462.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,121671,,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,114206.41,79944.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,91365.128,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,70294.35,49206.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,109439.7848,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,25826.71,18078.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59750.4304,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,10589.98,7412.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3531.75833,35176.2776,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,134518.68,94163.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,107614.944,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,95919.47,67143.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,76735.576,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,68797.87,48158.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,55038.296,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,54280.26,37996.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,66232.884,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,53419.21,37393.447,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42735.368,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68987.67,48291.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,98422.248,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,77778.52,54444.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,62222.816,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,54869.65,38408.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47968.9408,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,71787.88,50251.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,90871.8816,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,33747.79,23623.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43711.4744,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,89768.8,62838.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71815.04,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,65676.03,45973.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,52540.824,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,26493.14,18545.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35982.7848,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,50028.86,35020.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59596.424,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,54052.44,37836.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43241.952,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,42724.18,29906.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34179.344,,
Knee Procedures With Principal Diagnosis Of Infection With McC,485,MS-DRG,,,,,,,inpatient,,,78688.59,55082.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,65323.0304,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,38633.42,27043.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42973.8648,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,68635.57,48044.899,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,54908.456,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,35436.81,24805.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28349.448,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,77413.36,54189.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71957.464,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,79988.8,55992.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,63991.04,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,52007.74,36405.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,41606.192,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC,495,MS-DRG,,,,,,,inpatient,,,55215.82,38651.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71335.3592,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC,499,MS-DRG,,,,,,,inpatient,,,24343.66,17040.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,23522.4512,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,43692.12,30584.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,64206.484,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,30673.94,21471.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36169.2136,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,41306.96,28914.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,53628.676,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,37180.29,26026.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35575.4784,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,63266.34,44286.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50613.072,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,57782.59,40447.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,57914.512,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,39749.27,27824.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39745.8096,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,26213.06,18349.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30507.452,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,64680.35,45276.245,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,62660.3408,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,33187.16,23231.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40763.0624,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,28664.41,20065.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30246.0464,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,52006.98,36404.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,72622.1232,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,60945.78,42662.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48756.624,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,27733.63,19413.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29040.3384,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,64155.47,44908.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59061.4544,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59467.45,41627.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47573.96,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,24348.24,17043.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26949.0936,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,14748.61,10324.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4918.661435,16432.0776,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,34525.72,24168.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40987.9928,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,27528.18,19269.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26229.7216,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,28046.03,19632.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37790.3336,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,29133.49,20393.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7548.68,23306.792,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,17251.52,12076.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5616.11,15313.5048,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,10607.77,7425.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3537.691295,51201.0488,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,22929.4,16050.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7646.9549,23459.6328,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,15898.64,11129.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5302.19644,15120.9968,,
Septic Arthritis Without Cc/McC,550,MS-DRG,,,,,,,inpatient,,,13751.03,9625.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4585.968505,17469.5944,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,34050.51,23835.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34576.4632,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,21070.26,14749.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6815.74,19530.4432,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,37105.01,25973.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29684.008,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,33214.93,23250.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5718.85,26571.944,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC,555,MS-DRG,,,,,,,inpatient,,,16910.44,11837.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5639.63174,27285.476,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,38978.42,27284.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5833.89,31182.736,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,25775.81,18043.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31403.1208,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,17322.32,12125.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5776.99372,17504.0432,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,46066.43,32246.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37612.0104,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,43659.99,30561.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34927.992,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,35419.71,24793.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5723.92,28335.768,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,23360.4,16352.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29660.4168,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,23376.03,16363.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6300.58,18700.824,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,24152.97,16907.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31798.2688,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,26103.05,18272.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7280.97,20882.44,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,12203.73,8542.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4069.943955,15157.472,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,58121.61,40685.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,61002.7456,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,22908.56,16035.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7640.00476,33938.1472,,
Skin Debridement Without Cc/McC,572,MS-DRG,,,,,,,inpatient,,,34042.21,23829.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,27233.768,,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,40320.12,28224.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,124781.6592,,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,31675.49,22172.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,70208.6808,,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC,575,MS-DRG,,,,,,,inpatient,,,33248.67,23274.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40457.076,,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,inpatient,,,22694.73,15886.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7568.692455,53954.9264,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,47774,33441.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,66042.4024,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,21385.31,14969.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7132.000885,35926.0456,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,107178.51,75024.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,85742.808,,
Breast Biopsy- Local Excision And Other Breast Procedures Without Cc/McC,585,MS-DRG,,,,,,,inpatient,,,37278.64,26095.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40224.04,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,53897.07,37727.949,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43117.656,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,22540.18,15778.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5923.61,18032.144,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,26958.01,18870.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7157.25,21905.384,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,36927.76,25849.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35593.716,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,9105.56,6373.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3036.70426,21862.8296,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,5148.62,3604.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1717.06477,12148.268,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,21201.17,14840.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7070.590195,29775.9216,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,14711.96,10298.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4906.43866,17850.5576,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,29329.16,20530.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30106.2248,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21984.9,15389.43,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6578.42,18717.8568,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,26207.89,18345.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32627.0664,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,18364.58,12855.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5973.54,17514.1752,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,63303.79,44312.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,78318.3336,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,33293.26,23305.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39154.1008,,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,inpatient,,,47713.27,33399.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38170.616,,
O.R. Procedures For Obesity Without Cc/McC,621,MS-DRG,,,,,,,inpatient,,,43994.97,30796.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35195.976,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,39685.45,27779.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,75868.416,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,19840.3,13888.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6616.74005,38785.296,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,624,MS-DRG,,,,,,,inpatient,,,15962.42,11173.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5323.46707,20326.8184,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,76735.34,53714.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,79967.8232,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,36824.85,25777.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45596.0264,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,27285.79,19100.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29510.4632,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,17323.96,12126.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5777.54066,18586.1408,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,11395.93,7977.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3800.542655,12697.4224,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,21542.6,15079.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7184.4571,26912.6184,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,14225.97,9958.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4744.360995,15836.316,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,13622.93,9536.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4543.247155,25149.6504,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,60349.49,42244.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48279.592,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,13236.15,9265.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4414.256025,20942.844,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,16049.47,11234.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4345.13148,15785.656,,
Major Bladder Procedures Without Cc/McC,655,MS-DRG,,,,,,,inpatient,,,55359.22,38751.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44287.376,,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,47307.79,33115.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,66014.0328,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,42988.03,30091.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37042.592,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,30491.37,21343.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,52366.2288,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,26889.16,18822.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,27151.7336,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,19523.55,13666.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6511.103925,20803.0224,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,57156.94,40009.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,63211.5216,,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,29787.18,20851.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30949.2072,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,15013.42,10509.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5006.97557,21881.0672,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,28865.76,20206.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,69574.4176,,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,28047.28,19633.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33378.8608,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,51984.11,36388.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59091.8504,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,30494.67,21346.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31358.54,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,12447.8,8713.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4151.3413,19364.2784,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,72572.36,50800.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,84906.16,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,49815.27,34870.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46775.3912,,
Other Kidney And Urinary Tract Procedures Without Cc/McC,675,MS-DRG,,,,,,,inpatient,,,67065.03,46945.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,53652.024,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25198.22,17638.754,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30436.528,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,16815.75,11771.025,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5608.052625,18012.6696,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,11199.54,7839.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3735.04659,12310.38,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,17030.3,11921.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5679.60505,38209.7984,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,10555.37,7388.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3520.215895,21329.8864,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,21612.22,15128.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7207.67537,23716.9856,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,14540.91,10178.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4849.393485,16263.8864,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,27273.94,19091.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29794.1592,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,11406.89,7984.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3804.197815,15834.2896,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,22314.56,15620.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7441.90576,22851.7128,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,14767.92,10337.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4925.10132,14016.6088,,
Urethral Stricture,697,MS-DRG,,,,,,,inpatient,,,14675.76,10273.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4894.36596,20300.4752,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,24798.67,17359.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34061.7576,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,17120.52,11984.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5709.69342,20665.2272,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,41107.29,28775.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5388.92,32885.832,,
Major Male Pelvic Procedures With Cc/McC,707,MS-DRG,,,,,,,inpatient,,,35017.36,24512.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39322.292,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,31613.04,22129.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30039.3536,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,20964.14,14674.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6991.54069,45533.208,,
Penis Procedures Without Cc/McC,710,MS-DRG,,,,,,,inpatient,,,68393.44,47875.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,54714.752,,
Testes Procedures With Cc/McC,711,MS-DRG,,,,,,,inpatient,,,36907.35,25835.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38716.3984,,
Testes Procedures Without Cc/McC,712,MS-DRG,,,,,,,inpatient,,,18463.04,12924.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6157.42384,21674.3744,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,14941.94,10459.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4983.13699,29299.7176,,
Transurethral Prostatectomy Without Cc/McC,714,MS-DRG,,,,,,,inpatient,,,10164.77,7115.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3389.950795,19040.0544,,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC,715,MS-DRG,,,,,,,inpatient,,,36701.12,25690.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45760.1648,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,23580.89,16506.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37597.8256,,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC,718,MS-DRG,,,,,,,inpatient,,,27747.61,19423.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,24961.1952,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,48176.72,33723.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38541.376,,
Benign Prostatic Hypertrophy With McC,725,MS-DRG,,,,,,,inpatient,,,31783.16,22248.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25595.4584,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,10731.22,7511.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3578.86187,15082.4952,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,9268.85,6488.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3091.161475,16557.7144,,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC,739,MS-DRG,,,,,,,inpatient,,,70791.15,49553.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,80664.9048,,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,inpatient,,,61565.64,43095.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,49252.512,,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC,741,MS-DRG,,,,,,,inpatient,,,66917.01,46841.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,53533.608,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,24878.38,17414.866,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37014.2224,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,27909.66,19536.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,24288.4304,,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,16030.6,11221.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5346.2051,19354.1464,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,22664.36,15865.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7558.56406,22495.0664,,
Infections- Female Reproductive System With McC,757,MS-DRG,,,,,,,inpatient,,,15549.35,10884.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5185.708225,28677.6128,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,10151.59,7106.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3385.555265,20655.0952,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,10881.96,7617.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3629.13366,19970.172,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14849.95,10394.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4952.458325,13906.65298,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,25190.93,17633.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28156.828,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,6415.51,4490.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2139.572585,21802.0376,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,10227.7,7159.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3410.93795,14456.3376,,
Abortion Without D&C,779,MS-DRG,,,,,,,inpatient,,,13854.84,9698.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4620.58914,18940.7608,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,19969.28,13978.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6659.75488,23129.64586,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,17660.24,12362.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5889.69004,14128.192,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,16297.53,11408.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5435.226255,13038.024,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,19789.47,13852.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6599.788245,20332.32622,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,17268.46,12087.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5759.03141,13814.768,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,16414.17,11489.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5474.125695,13131.336,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,3982.92,2788.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1584.915395,22641.16608,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,54759.69,38331.783,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2909,73865.99995,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39693.75,27785.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2909,50556.23959,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,7967.7,5577.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2657.22795,30643.57784,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,10068.5,7047.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2909,51923.98297,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5320.51,3724.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1774.390085,18604.71546,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4248.78,2974.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1378.34,7947.23,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,9202.02,6441.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3068.87367,12322.49451,,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,inpatient,,,55562.6,38893.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59041.1904,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,36233.96,25363.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28987.168,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,14129.33,9890.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4712.131555,12691.01849,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13166.38,9216.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4390.98773,10533.104,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,12520.32,8764.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4175.52672,10016.256,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,50163.84,35114.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46412.6656,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,18648.29,13053.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6219.204715,25096.964,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,10877.8,7614.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3627.7463,19285.2488,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,32327.52,22629.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28507.3952,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,22300.24,15610.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6364.97,18701.6456,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,33797.91,23658.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31366.6456,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,19042.28,13329.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6350.60038,42357.8392,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,19035.73,13325.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6348.415955,20590.2504,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,34218.62,23953.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,51371.2664,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,53653,37557.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45233.3008,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,70337.4,49236.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,94819.3088,,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,inpatient,,,93776.03,65643.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,75020.824,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,73575.27,51502.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,96764.6528,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,inpatient,,,54189.56,37932.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47816.9608,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,45890.81,32123.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36712.648,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,19580.15,13706.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6529.980025,62486.0704,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC,830,MS-DRG,,,,,,,inpatient,,,39587.15,27711.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31669.72,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,19450.76,13615.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6486.82846,23321.8376,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,17150.01,12005.007,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5642.16,15143.2872,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,11361.65,7953.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3789.110275,10533.2272,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,9828.38,6879.866,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3277.76473,111997.1016,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,18619.01,13033.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6209.439835,43279.8512,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,24808.35,17365.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,64630.0016,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,16962.7,11873.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5657.06045,31771.9256,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,31741.3,22218.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25393.04,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,19222.18,13455.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6410.59703,38361.7784,,
Radiotherapy,849,MS-DRG,,,,,,,inpatient,,,58144.26,40700.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,54123.1176,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,85769.92,60038.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,101350.396,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,33994.9,23796.43,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40491.5248,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65980.01,46186.007,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,91416.9832,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,32658.71,22861.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44153.2296,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,20565.93,14396.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6858.737655,37257.3904,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,17400.21,12180.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5802.970035,20261.9736,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,17612.23,12328.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5873.678705,18195.0456,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,43267.27,30287.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34613.816,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,18403.74,12882.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6057.47,17927.5608,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,61414.22,42989.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,49131.376,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,15482.04,10837.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5163.26034,21277.2,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,13610,9527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4538.935,14579.948,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,148503.39,103952.373,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,140966.516,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,33194.92,23236.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39764.0472,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,18792.68,13154.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6267.35878,20892.184,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,12279.31,8595.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4095.149885,19425.0704,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,25117.86,17582.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33842.9064,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,22405.38,15683.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7472.19423,28562.108,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,13917.07,9741.949,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3961.38,12646.7624,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,48007.28,33605.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38405.824,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,20565.28,14395.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5972.81,17876.9008,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,61408.52,42985.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,80721.644,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,50016.36,35011.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40872.488,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,27835,19484.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25698.8048,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,30162.14,21113.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32791.2048,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42212,29548.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35214.7792,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,17347.78,12143.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4755.82,13878.224,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,43962.28,30773.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35169.824,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,17818.34,12472.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5723.92,17921.4816,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,31482.85,22037.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36949.3776,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,15673.65,10971.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5227.162275,20584.1712,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,7247.46,5073.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2417.02791,13933.5264,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,28001.68,19601.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6731.81,22401.344,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC,939,MS-DRG,,,,,,,inpatient,,,23950.54,16765.378,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,64313.8832,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,49540.17,34678.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42783.3832,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC,941,MS-DRG,,,,,,,inpatient,,,17064.75,11945.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5691.094125,39599.9088,,
Rehabilitation With Cc/McC,945,MS-DRG,,,,,,,inpatient,,,45131.85,31592.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36105.48,,
Rehabilitation Without Cc/McC,946,MS-DRG,,,,,,,inpatient,,,44615.43,31230.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35692.344,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,22069.35,15448.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7360.128225,26061.5304,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,17906.41,12534.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5684.12,16099.748,,
Aftercare With Cc/McC,949,MS-DRG,,,,,,,inpatient,,,33492.73,23444.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26794.184,,
Aftercare Without Cc/McC,950,MS-DRG,,,,,,,inpatient,,,9898.64,6929.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3301.19644,11876.7304,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,4337.06,3035.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1446.40951,11487.6616,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,61892.75,43324.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,77453.0608,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,12905.91,9034.137,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4304.120985,30400.0528,,
Other Multiple Significant Trauma Without Cc/McC,965,MS-DRG,,,,,,,inpatient,,,19234.18,13463.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6414.59903,18490.9,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,37958.81,26571.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,60508.304,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,12545.67,8781.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4183.980945,29216.6352,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,108861.48,76203.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,96341.1352,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,62893.24,44025.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50314.592,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,59507.83,41655.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47606.264,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51559.92,36091.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,70984.792,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,16279.53,11395.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5429.223255,34773.024,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,989,MS-DRG,,,,,,,inpatient,,,64497.43,45148.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,51597.944,,
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,inpatient,,,7296.22,5107.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2433.28937,7947.23,,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,001-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,154357.8,,,154357.8,127777.5356,154357.7988,case rate,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,001-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,173852.18,,,173852.18,127777.5356,173852.1792,case rate,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,001-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,207431.81,,,207431.81,173454.278,207431.8056,case rate,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,001-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,358797.58,,,358797.58,358797.5832,362921.9528,case rate,
HEART AND/OR LUNG TRANSPLANT,002-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,220807.17,,,220807.17,220807.1652,250859.2732,case rate,
HEART AND/OR LUNG TRANSPLANT,002-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,257571.28,,,257571.28,257571.282,266319.1256,case rate,
HEART AND/OR LUNG TRANSPLANT,002-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,347079.46,,,347079.46,312406.3616,347079.4584,case rate,
HEART AND/OR LUNG TRANSPLANT,002-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,561267.68,,,561267.68,561267.6828,723409.9688,case rate,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,004-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,114506.68,,,114506.68,114506.676,149034.0552,case rate,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,004-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171472.56,,,171472.56,149034.0552,171472.56,case rate,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,004-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,249412.59,,,249412.59,208783.6792,249412.5876,case rate,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,004-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,364464.18,,,364464.18,364464.1764,374670.7772,case rate,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,005-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,107510.3,,,107510.3,107510.2956,118091.5452,case rate,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,005-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,129466.78,,,129466.78,121149.5152,129466.782,case rate,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,005-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176871.7,,,176871.7,176871.696,191412.3364,case rate,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,005-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240189.06,,,240189.06,240189.0636,285883.914,case rate,
PANCREAS TRANSPLANT,006-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,152030.67,,,152030.67,104808.5528,152030.6712,case rate,
PANCREAS TRANSPLANT,006-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,193411.55,,,193411.55,104808.5528,193411.5492,case rate,
PANCREAS TRANSPLANT,006-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,222799.35,,,222799.35,151637.9944,222799.3464,case rate,
PANCREAS TRANSPLANT,006-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,316859.29,,,316859.29,158369.6748,316859.2944,case rate,
ALLOGENEIC BONE MARROW TRANSPLANT,007-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,151033.33,,,151033.33,151033.3308,151033.3308,case rate,
ALLOGENEIC BONE MARROW TRANSPLANT,007-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,169620.36,,,169620.36,169620.3564,169620.3564,case rate,
ALLOGENEIC BONE MARROW TRANSPLANT,007-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,216847.8,,,216847.8,216847.7988,216847.7988,case rate,
ALLOGENEIC BONE MARROW TRANSPLANT,007-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,367958.62,,,367958.62,367958.6172,367958.6172,case rate,
AUTOLOGOUS BONE MARROW TRANSPLANT,008-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,73690.71,,,73690.71,73690.7076,73690.7076,case rate,
AUTOLOGOUS BONE MARROW TRANSPLANT,008-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98064.31,,,98064.31,98064.3072,98064.3072,case rate,
AUTOLOGOUS BONE MARROW TRANSPLANT,008-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,117206.24,,,117206.24,117206.244,117206.244,case rate,
AUTOLOGOUS BONE MARROW TRANSPLANT,008-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,186135.21,,,186135.21,186135.2136,186135.2136,case rate,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),009-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98439.25,,,98439.25,98439.2472,98439.2472,case rate,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),009-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,119948.31,,,119948.31,119948.3052,119948.3052,case rate,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),009-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,164456.18,,,164456.18,164456.1828,164456.1828,case rate,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),009-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,356820.4,,,356820.4,356820.3996,356820.3996,case rate,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,011-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,67231.74,,,67231.74,67231.7412,67231.7412,case rate,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,011-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,99759.04,,,99759.04,99759.036,99759.036,case rate,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,011-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,188332.36,,,188332.36,188332.362,188332.362,case rate,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,011-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,382613.77,,,382613.77,382613.772,382613.772,case rate,
OPEN CRANIOTOMY FOR TRAUMA,020-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51019.34,,,51019.34,37019.0592,51019.3356,case rate,
OPEN CRANIOTOMY FOR TRAUMA,020-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61290.19,,,61290.19,46758.9528,61290.192,case rate,
OPEN CRANIOTOMY FOR TRAUMA,020-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83861.58,,,83861.58,73441.0368,83861.58,case rate,
OPEN CRANIOTOMY FOR TRAUMA,020-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,131104.02,,,131104.02,131104.02,138697.08,case rate,
OPEN CRANIOTOMY EXCEPT TRAUMA,021-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47827.35,,,47827.35,39268.4812,47827.3464,case rate,
OPEN CRANIOTOMY EXCEPT TRAUMA,021-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60880.26,,,60880.26,55503.7104,60880.2576,case rate,
OPEN CRANIOTOMY EXCEPT TRAUMA,021-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91082.92,,,91082.92,89808.9508,91082.9244,case rate,
OPEN CRANIOTOMY EXCEPT TRAUMA,021-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,142107.26,,,142107.26,142107.2592,150128.7048,case rate,
VENTRICULAR SHUNT PROCEDURES,022-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32607.28,,,32607.28,26429.1536,32607.282,case rate,
VENTRICULAR SHUNT PROCEDURES,022-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38671.31,,,38671.31,33793.16,38671.3116,case rate,
VENTRICULAR SHUNT PROCEDURES,022-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53771.4,,,53771.4,53771.3952,55395.904,case rate,
VENTRICULAR SHUNT PROCEDURES,022-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108595.12,,,108595.12,108595.122,111693.65,case rate,
SPINAL PROCEDURES,023-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38336.37,,,38336.37,34021.212,38336.3652,case rate,
SPINAL PROCEDURES,023-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52556.59,,,52556.59,45734.792,52556.5896,case rate,
SPINAL PROCEDURES,023-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,88535.83,,,88535.83,88535.832,89072.9648,case rate,
SPINAL PROCEDURES,023-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144081.94,,,144081.94,144081.9432,167558.0972,case rate,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,024-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25615.9,,,25615.9,25615.9008,31133.2444,case rate,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,024-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31957.39,,,31957.39,31957.386,44169.526,case rate,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,024-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55846.06,,,55846.06,55846.0632,76507.2996,case rate,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,024-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95024.79,,,95024.79,95024.7936,140844.9152,case rate,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,026-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30210.17,,,30210.17,25431.9444,30210.1656,case rate,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,026-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38273.88,,,38273.88,37234.672,38273.8752,case rate,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,026-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58518.14,,,58518.14,55321.2688,58518.1356,case rate,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,026-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,109250.02,,,109250.02,109250.0172,130111.9588,case rate,
OTHER OPEN CRANIOTOMY,027-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40166.07,,,40166.07,40166.0724,40166.0724,case rate,
OTHER OPEN CRANIOTOMY,027-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46755.02,,,46755.02,46755.018,46755.018,case rate,
OTHER OPEN CRANIOTOMY,027-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75970.34,,,75970.34,75970.3428,75970.3428,case rate,
OTHER OPEN CRANIOTOMY,027-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,125259.96,,,125259.96,125259.9552,125259.9552,case rate,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,029-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45507.72,,,45507.72,45507.7176,45507.7176,case rate,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,029-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47782.35,,,47782.35,47782.3536,47782.3536,case rate,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,029-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61482.66,,,61482.66,61482.6612,61482.6612,case rate,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,029-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101551.25,,,101551.25,101551.2492,101551.2492,case rate,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,030-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45745.18,,,45745.18,45745.1796,45745.1796,case rate,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,030-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61297.69,,,61297.69,61297.6908,61297.6908,case rate,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,030-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83981.56,,,83981.56,83981.5608,83981.5608,case rate,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,030-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,110877.26,,,110877.26,110877.2568,110877.2568,case rate,
SPINAL DISORDERS AND INJURIES,040-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21426.57,,,21426.57,16915.2388,21426.5712,case rate,
SPINAL DISORDERS AND INJURIES,040-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30135.18,,,30135.18,26626.1076,30135.1776,case rate,
SPINAL DISORDERS AND INJURIES,040-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41848.3,,,41848.3,41848.3032,47611.038,case rate,
SPINAL DISORDERS AND INJURIES,040-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,67841.64,,,67841.64,56308.112,67841.6436,case rate,
NERVOUS SYSTEM MALIGNANCY,041-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17257.24,,,17257.24,15565.5856,17257.2384,case rate,
NERVOUS SYSTEM MALIGNANCY,041-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19234.42,,,19234.42,17962.2048,19234.422,case rate,
NERVOUS SYSTEM MALIGNANCY,041-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25408.43,,,25408.43,25408.434,30556.8948,case rate,
NERVOUS SYSTEM MALIGNANCY,041-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37591.48,,,37591.48,37591.4844,56625.3116,case rate,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,042-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16069.93,,,16069.93,13210.4304,16069.9284,case rate,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,042-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20396.74,,,20396.74,18300.1364,20396.736,case rate,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,042-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27443.11,,,27443.11,27443.1084,37850.4124,case rate,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,042-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48864.68,,,48864.68,40290.5688,48864.6804,case rate,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",043-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19646.86,,,19646.86,16251.8148,19646.856,case rate,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",043-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26455.77,,,26455.77,22282.7536,26455.7664,case rate,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",043-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41010.94,,,41010.94,41010.9372,46814.9292,case rate,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",043-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74773.03,,,74773.03,74773.0344,122685.7564,case rate,
INTRACRANIAL HEMORRHAGE,044-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17877.14,,,17877.14,17877.1392,20734.0732,case rate,
INTRACRANIAL HEMORRHAGE,044-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25023.5,,,25023.5,25023.4956,30332.9892,case rate,
INTRACRANIAL HEMORRHAGE,044-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32767.26,,,32767.26,32767.2564,43858.546,case rate,
INTRACRANIAL HEMORRHAGE,044-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36509.16,,,36509.16,36509.1576,57608.0084,case rate,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,045-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19026.96,,,19026.96,16529.6236,19026.9552,case rate,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,045-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23536.23,,,23536.23,23039.4716,23536.2336,case rate,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,045-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31504.96,,,31504.96,31504.9584,35685.9916,case rate,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,045-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47362.42,,,47362.42,47362.4208,70907.5864,case rate,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,046-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15617.5,,,15617.5,13092.258,15617.5008,case rate,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,046-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19691.85,,,19691.85,17589.0288,19691.8488,case rate,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,046-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24326.11,,,24326.11,22925.4456,24326.1072,case rate,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,046-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42695.67,,,42695.67,23955.826,42695.6676,case rate,
TRANSIENT ISCHEMIA,047-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15922.45,,,15922.45,10643.8088,15922.452,case rate,
TRANSIENT ISCHEMIA,047-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18172.09,,,18172.09,13121.2828,18172.092,case rate,
TRANSIENT ISCHEMIA,047-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22821.35,,,22821.35,18152.9392,22821.348,case rate,
TRANSIENT ISCHEMIA,047-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37126.56,,,37126.56,18586.238,37126.5588,case rate,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",048-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14830.13,,,14830.13,11481.3816,14830.1268,case rate,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",048-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17077.27,,,17077.27,15327.1676,17077.2672,case rate,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",048-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23176.29,,,23176.29,22931.6652,23176.2912,case rate,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",048-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42970.62,,,42970.62,42970.6236,72236.5076,case rate,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,049-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22721.36,,,22721.36,22721.364,24148.6336,case rate,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,049-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45070.29,,,45070.29,45070.2876,51604.0212,case rate,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,049-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50209.47,,,50209.47,50209.4652,66352.766,case rate,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,049-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84041.55,,,84041.55,84041.5512,123718.21,case rate,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,050-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15742.48,,,15742.48,15559.366,15742.4808,case rate,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,050-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27355.62,,,27355.62,27355.6224,28040.03,case rate,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,050-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43388.06,,,43388.06,43388.0568,45705.7672,case rate,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,050-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,88873.28,,,88873.28,88873.278,110843.638,case rate,
VIRAL MENINGITIS,051-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11545.65,,,11545.65,11545.6524,12795.7904,case rate,
VIRAL MENINGITIS,051-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17389.72,,,17389.72,16237.3024,17389.7172,case rate,
VIRAL MENINGITIS,051-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28900.38,,,28900.38,28900.3752,31446.2976,case rate,
VIRAL MENINGITIS,051-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,57468.3,,,57468.3,35885.0188,57468.3036,case rate,
ALTERATION IN CONSCIOUSNESS,052-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13975.26,,,13975.26,11512.4796,13975.2636,case rate,
ALTERATION IN CONSCIOUSNESS,052-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16542.35,,,16542.35,15068.0176,16542.3528,case rate,
ALTERATION IN CONSCIOUSNESS,052-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21504.06,,,21504.06,20779.6836,21504.0588,case rate,
ALTERATION IN CONSCIOUSNESS,052-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42055.77,,,42055.77,42055.77,47210.9104,case rate,
SEIZURE,053-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11838.11,,,11838.11,10117.216,11838.1056,case rate,
SEIZURE,053-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15097.58,,,15097.58,12068.0972,15097.584,case rate,
SEIZURE,053-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19671.85,,,19671.85,16998.1668,19671.852,case rate,
SEIZURE,053-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44760.34,,,44760.34,44760.3372,55497.4908,case rate,
MIGRAINE AND OTHER HEADACHES,054-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13282.87,,,13282.87,10202.2172,13282.8744,case rate,
MIGRAINE AND OTHER HEADACHES,054-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16172.41,,,16172.41,12692.1304,16172.412,case rate,
MIGRAINE AND OTHER HEADACHES,054-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20129.28,,,20129.28,16376.2068,20129.2788,case rate,
MIGRAINE AND OTHER HEADACHES,054-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31434.97,,,31434.97,16676.8208,31434.9696,case rate,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,055-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15257.56,,,15257.56,11545.6508,15257.5584,case rate,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,055-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21491.56,,,21491.56,18192.33,21491.5608,case rate,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,055-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32207.35,,,32207.35,31114.5856,32207.346,case rate,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,055-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56905.89,,,56905.89,56905.8936,70140.5024,case rate,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",056-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14505.18,,,14505.18,10766.1276,14505.1788,case rate,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",056-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20704.19,,,20704.19,16618.7712,20704.1868,case rate,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",056-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28507.94,,,28507.94,28507.938,29578.3444,case rate,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",056-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45660.19,,,45660.19,45660.1932,78864.528,case rate,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",057-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13010.42,,,13010.42,8228.5308,13010.418,case rate,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",057-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19389.4,,,19389.4,11193.2068,19389.3972,case rate,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",057-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28555.43,,,28555.43,20076.8688,28555.4304,case rate,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",057-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47197.45,,,47197.45,47197.4472,61238.1816,case rate,
OTHER DISORDERS OF NERVOUS SYSTEM,058-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18864.48,,,18864.48,11164.182,18864.4812,case rate,
OTHER DISORDERS OF NERVOUS SYSTEM,058-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25313.45,,,25313.45,16231.0828,25313.4492,case rate,
OTHER DISORDERS OF NERVOUS SYSTEM,058-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33162.19,,,33162.19,26211.4676,33162.1932,case rate,
OTHER DISORDERS OF NERVOUS SYSTEM,058-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46145.12,,,46145.12,46145.1156,70246.2356,case rate,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,059-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12642.98,,,12642.98,12642.9768,12642.9768,case rate,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,059-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20764.18,,,20764.18,20764.1772,20764.1772,case rate,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,059-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29290.31,,,29290.31,29290.3128,29290.3128,case rate,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,059-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40541.01,,,40541.01,40541.0124,40541.0124,case rate,
ORBIT AND EYE PROCEDURES,073-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22073.97,,,22073.97,13662.388,22073.9676,case rate,
ORBIT AND EYE PROCEDURES,073-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28020.52,,,28020.52,17539.272,28020.516,case rate,
ORBIT AND EYE PROCEDURES,073-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43847.98,,,43847.98,43847.9832,51100.2336,case rate,
ORBIT AND EYE PROCEDURES,073-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84576.47,,,84576.47,53418.0712,84576.4656,case rate,
EYE INFECTIONS AND OTHER EYE DISORDERS,082-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13182.89,,,13182.89,10148.314,13182.8904,case rate,
EYE INFECTIONS AND OTHER EYE DISORDERS,082-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16199.91,,,16199.91,12304.442,16199.9076,case rate,
EYE INFECTIONS AND OTHER EYE DISORDERS,082-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23576.23,,,23576.23,21273.1052,23576.2272,case rate,
EYE INFECTIONS AND OTHER EYE DISORDERS,082-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46580.05,,,46580.05,21870.1868,46580.046,case rate,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,089-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37973.92,,,37973.92,28266.0088,37973.9232,case rate,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,089-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50826.87,,,50826.87,44826.7304,50826.8664,case rate,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,089-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,92847.64,,,92847.64,78988.92,92847.642,case rate,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,089-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,133693.61,,,133693.61,133693.6056,141363.2152,case rate,
OTHER MAJOR HEAD AND NECK PROCEDURES,091-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35919.25,,,35919.25,27668.9272,35919.252,case rate,
OTHER MAJOR HEAD AND NECK PROCEDURES,091-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53918.87,,,53918.87,53918.8716,59065.468,case rate,
OTHER MAJOR HEAD AND NECK PROCEDURES,091-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95992.14,,,95992.14,76389.1272,95992.1388,case rate,
OTHER MAJOR HEAD AND NECK PROCEDURES,091-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,150393.43,,,150393.43,85886.4564,150393.4332,case rate,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,092-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30647.6,,,30647.6,21801.7712,30647.5956,case rate,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,092-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39458.69,,,39458.69,28288.814,39458.6856,case rate,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,092-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61860.1,,,61860.1,45179.1744,61860.1008,case rate,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,092-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118975.96,,,118975.96,118975.9608,152450.6888,case rate,
CLEFT LIP AND PALATE REPAIR,095-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19584.37,,,19584.37,14862.7708,19584.366,case rate,
CLEFT LIP AND PALATE REPAIR,095-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22621.38,,,22621.38,18803.924,22621.38,case rate,
CLEFT LIP AND PALATE REPAIR,095-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36556.65,,,36556.65,28742.8448,36556.65,case rate,
CLEFT LIP AND PALATE REPAIR,095-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52189.15,,,52189.15,52189.1484,52731.842,case rate,
TONSIL AND ADENOID PROCEDURES,097-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12712.97,,,12712.97,10038.4344,12712.9656,case rate,
TONSIL AND ADENOID PROCEDURES,097-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18422.05,,,18422.05,14317.5192,18422.052,case rate,
TONSIL AND ADENOID PROCEDURES,097-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28332.97,,,28332.97,28332.966,30664.7012,case rate,
TONSIL AND ADENOID PROCEDURES,097-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65079.59,,,65079.59,65079.5856,82393.1144,case rate,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",098-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20329.25,,,20329.25,14195.2004,20329.2468,case rate,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",098-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28148,,,28148,20219.9196,28147.9956,case rate,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",098-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47334.93,,,47334.93,38629.9356,47334.9252,case rate,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",098-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,80754.58,,,80754.58,80754.5772,86276.218,case rate,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",110-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17174.75,,,17174.75,7804.554759,17174.7516,case rate,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",110-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19644.36,,,19644.36,10054.75053,19969.08136,case rate,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",110-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28457.95,,,28457.95,18364.0221,36768.202,case rate,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",110-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46340.08,,,46340.08,29642.21606,75209.4764,case rate,
VERTIGO AND OTHER LABYRINTH DISORDERS,111-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13335.37,,,13335.37,4173.810074,13335.366,case rate,
VERTIGO AND OTHER LABYRINTH DISORDERS,111-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15320.05,,,15320.05,5069.434998,15320.0484,case rate,
VERTIGO AND OTHER LABYRINTH DISORDERS,111-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18497.04,,,18497.04,7409.93549,18497.04,case rate,
VERTIGO AND OTHER LABYRINTH DISORDERS,111-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32429.81,,,32429.81,16098.398,32429.8104,case rate,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8018.72,,,8018.72,3541.677013,8046.0892,case rate,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11833.11,,,11833.11,5316.845198,11833.1064,case rate,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17242.24,,,17242.24,9272.934296,17242.2408,case rate,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28197.99,,,28197.99,20706.99669,43255.2448,case rate,
DENTAL DISEASES AND DISORDERS,114-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9488.48,,,9488.48,4800.994931,9924.4084,case rate,
DENTAL DISEASES AND DISORDERS,114-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13095.4,,,13095.4,5801.76919,13095.4044,case rate,
DENTAL DISEASES AND DISORDERS,114-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21031.63,,,21031.63,12922.23475,24874.2536,case rate,
DENTAL DISEASES AND DISORDERS,114-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36811.61,,,36811.61,22504.43179,51689.32038,case rate,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",115-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11040.73,,,11040.73,5154.791517,11040.7332,case rate,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",115-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15257.56,,,15257.56,7210.770279,15257.5584,case rate,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",115-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23088.81,,,23088.81,11860.84499,23439.22188,case rate,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",115-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42233.24,,,42233.24,23846.63213,54355.1576,case rate,
MAJOR RESPIRATORY AND CHEST PROCEDURES,120-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44865.32,,,44865.32,16750.90759,44865.3204,case rate,
MAJOR RESPIRATORY AND CHEST PROCEDURES,120-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55086.18,,,55086.18,22197.64314,55086.1848,case rate,
MAJOR RESPIRATORY AND CHEST PROCEDURES,120-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74813.03,,,74813.03,35911.59053,74813.028,case rate,
MAJOR RESPIRATORY AND CHEST PROCEDURES,120-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,130499.12,,,130499.12,76282.74992,130499.1168,case rate,
OTHER RESPIRATORY AND CHEST PROCEDURES,121-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32674.77,,,32674.77,12586.99393,32674.7712,case rate,
OTHER RESPIRATORY AND CHEST PROCEDURES,121-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42243.24,,,42243.24,16524.52726,42243.24,case rate,
OTHER RESPIRATORY AND CHEST PROCEDURES,121-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64252.22,,,64252.22,32257.34188,64252.218,case rate,
OTHER RESPIRATORY AND CHEST PROCEDURES,121-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106700.43,,,106700.43,50793.31406,125575.7972,case rate,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,130-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,78087.5,,,78087.5,44137.97968,78087.504,case rate,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,130-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,78105,,,78105,44144.16494,78105.0012,case rate,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,130-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95607.2,,,95607.2,50414.77645,95607.2004,case rate,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,130-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,123842.68,,,123842.68,64377.37109,125901.2896,case rate,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25918.35,,,25918.35,18351.65159,28610.16,case rate,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36466.66,,,36466.66,30617.01225,37344.57067,case rate,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48574.73,,,48574.73,33589.6458,52937.0888,case rate,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63052.41,,,63052.41,47173.70283,71140.134,case rate,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9368.5,,,9368.5,6492.043648,12236.0264,case rate,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12300.53,,,12300.53,9144.280992,16260.1076,case rate,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20664.19,,,20664.19,18082.29561,27318.5564,case rate,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32922.23,,,32922.23,27233.67777,49773.3856,case rate,
RESPIRATORY FAILURE,133-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10733.28,,,10733.28,6645.437972,19104.538,case rate,
RESPIRATORY FAILURE,133-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17719.66,,,17719.66,7074.694669,19143.9288,case rate,
RESPIRATORY FAILURE,133-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26685.73,,,26685.73,12283.91643,28336.4976,case rate,
RESPIRATORY FAILURE,133-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44045.45,,,44045.45,20103.3158,44045.4516,case rate,
PULMONARY EMBOLISM,134-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14002.76,,,14002.76,4556.058833,14609.8404,case rate,
PULMONARY EMBOLISM,134-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18234.58,,,18234.58,6642.96387,19386.4932,case rate,
PULMONARY EMBOLISM,134-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26305.79,,,26305.79,10252.67869,31292.8808,case rate,
PULMONARY EMBOLISM,134-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40041.09,,,40041.09,17673.74764,52999.2848,case rate,
MAJOR CHEST AND RESPIRATORY TRAUMA,135-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16967.28,,,16967.28,6071.446308,16967.2848,case rate,
MAJOR CHEST AND RESPIRATORY TRAUMA,135-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19744.34,,,19744.34,7148.917729,19744.3404,case rate,
MAJOR CHEST AND RESPIRATORY TRAUMA,135-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28322.97,,,28322.97,10658.43142,28322.9676,case rate,
MAJOR CHEST AND RESPIRATORY TRAUMA,135-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47714.86,,,47714.86,19730.96345,47714.8644,case rate,
RESPIRATORY MALIGNANCY,136-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14737.64,,,14737.64,6234.73704,16070.80662,case rate,
RESPIRATORY MALIGNANCY,136-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20394.24,,,20394.24,8144.743784,20394.2364,case rate,
RESPIRATORY MALIGNANCY,136-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28992.86,,,28992.86,12849.24874,32335.7004,case rate,
RESPIRATORY MALIGNANCY,136-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41100.92,,,41100.92,20995.22957,47550.9152,case rate,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,137-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15065.09,,,15065.09,5451.683757,15065.0892,case rate,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,137-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19199.43,,,19199.43,7466.839836,21370.5456,case rate,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,137-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26170.81,,,26170.81,9037.894606,34763.4176,case rate,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,137-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37803.95,,,37803.95,15549.73107,54154.0572,case rate,
BRONCHIOLITIS AND RSV PNEUMONIA,138-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7101.36,,,7101.36,3455.083443,10110.9964,case rate,
BRONCHIOLITIS AND RSV PNEUMONIA,138-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10170.87,,,10170.87,5805.480343,13067.3796,case rate,
BRONCHIOLITIS AND RSV PNEUMONIA,138-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16112.42,,,16112.42,7324.578971,28295.0336,case rate,
BRONCHIOLITIS AND RSV PNEUMONIA,138-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34254.52,,,34254.52,13445.50732,62687.3484,case rate,
OTHER PNEUMONIA,139-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11010.74,,,11010.74,4274.011205,11010.738,case rate,
OTHER PNEUMONIA,139-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15272.56,,,15272.56,5524.669766,15272.556,case rate,
OTHER PNEUMONIA,139-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21169.11,,,21169.11,8252.367221,23595.0892,case rate,
OTHER PNEUMONIA,139-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31839.9,,,31839.9,13963.83169,44984.2936,case rate,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13080.41,,,13080.41,4930.885286,13080.4068,case rate,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16109.92,,,16109.92,6179.069745,16109.922,case rate,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19534.37,,,19534.37,7526.218284,20987.0036,case rate,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28890.38,,,28890.38,12126.81095,40850.3328,case rate,
ASTHMA,141-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9248.52,,,9248.52,4437.301937,9818.6752,case rate,
ASTHMA,141-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13912.77,,,13912.77,5702.80511,13912.7736,case rate,
ASTHMA,141-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16732.32,,,16732.32,7042.531343,19440.3964,case rate,
ASTHMA,141-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29405.29,,,29405.29,11905.37882,34247.1908,case rate,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,142-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15147.58,,,15147.58,6514.310566,15147.576,case rate,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,142-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17837.15,,,17837.15,8622.24547,17837.1456,case rate,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,142-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24151.14,,,24151.14,11563.95275,27590.1456,case rate,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,142-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36414.17,,,36414.17,17954.55821,57668.1312,case rate,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",143-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12253.04,,,12253.04,5546.936684,12253.0392,case rate,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",143-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17362.22,,,17362.22,7136.547219,17362.2216,case rate,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",143-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24843.52,,,24843.52,11880.6378,26595.0096,case rate,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",143-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38261.38,,,38261.38,18578.03192,42660.2364,case rate,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",144-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11890.6,,,11890.6,5226.540475,11890.5972,case rate,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",144-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15650,,,15650,6706.053471,15649.9956,case rate,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",144-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22108.96,,,22108.96,10366.48738,22108.962,case rate,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",144-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38556.33,,,38556.33,14954.70954,38556.33,case rate,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,145-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11380.68,,,11380.68,4228.240318,11380.6788,case rate,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,145-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14547.67,,,14547.67,5174.584333,14547.672,case rate,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,145-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18769.5,,,18769.5,7909.704094,18769.4964,case rate,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,145-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28592.92,,,28592.92,14137.01883,30354.7162,case rate,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,69513.88,,,69513.88,32815.25188,74752.23481,case rate,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85621.3,,,85621.3,47755.1168,87402.47434,case rate,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,132108.86,,,132108.86,80727.47416,132108.8592,case rate,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,246103.12,,,246103.12,206156.9348,247472.8459,case rate,
IMPLANTABLE HEART ASSIST SYSTEMS,161-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,339865.61,,,339865.61,79731.80178,339865.6128,case rate,
IMPLANTABLE HEART ASSIST SYSTEMS,161-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,357755.25,,,357755.25,105224.0396,357755.25,case rate,
IMPLANTABLE HEART ASSIST SYSTEMS,161-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,445571.2,,,445571.2,172491.9223,445571.1972,case rate,
IMPLANTABLE HEART ASSIST SYSTEMS,161-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,581606.93,,,581606.93,352820.5528,581606.928,case rate,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,162-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,107445.31,,,107445.31,40249.92839,107445.306,case rate,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,162-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,125907.35,,,125907.35,46683.83064,125907.3516,case rate,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,162-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,158864.58,,,158864.58,60055.1149,158864.5776,case rate,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,162-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,231947.88,,,231947.88,91535.58875,231947.8824,case rate,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,163-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93974.96,,,93974.96,36385.38106,93974.9616,case rate,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,163-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,103988.36,,,103988.36,36882.67557,103988.3592,case rate,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,163-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,131396.47,,,131396.47,50725.27626,131396.4732,case rate,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,163-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,197373.42,,,197373.42,83557.84685,197373.4152,case rate,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,165-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91047.93,,,91047.93,44446.00538,91047.93,case rate,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,165-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,110872.26,,,110872.26,45162.25791,110872.2576,case rate,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,165-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,133306.17,,,133306.17,45972.52631,133306.1676,case rate,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,165-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,180493.62,,,180493.62,66108.00544,180493.6164,case rate,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,166-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83816.59,,,83816.59,24844.93228,83816.5872,case rate,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,166-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93327.57,,,93327.57,29920.55254,93327.5652,case rate,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,166-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,110829.76,,,110829.76,37668.20295,110829.7644,case rate,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,166-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,162698.96,,,162698.96,61902.03204,162698.964,case rate,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,167-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70466.22,,,70466.22,32102.7105,70466.2236,case rate,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,167-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,73245.78,,,73245.78,33589.6458,73245.7788,case rate,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,167-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,110579.8,,,110579.8,53570.49356,110579.8044,case rate,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,167-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,177539.09,,,177539.09,99594.97601,177539.0892,case rate,
MAJOR ABDOMINAL VASCULAR PROCEDURES,169-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70681.19,,,70681.19,25621.80031,70681.1892,case rate,
MAJOR ABDOMINAL VASCULAR PROCEDURES,169-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71633.54,,,71633.54,33672.52822,71633.5368,case rate,
MAJOR ABDOMINAL VASCULAR PROCEDURES,169-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93605.02,,,93605.02,40465.17526,93605.0208,case rate,
MAJOR ABDOMINAL VASCULAR PROCEDURES,169-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,152280.63,,,152280.63,68057.59782,152280.6312,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",170-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53011.52,,,53011.52,34434.55164,56092.4992,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",170-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60215.36,,,60215.36,37556.86836,60215.364,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",170-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76367.78,,,76367.78,44554.86587,76367.7792,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",170-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,107377.82,,,107377.82,59987.07709,107377.8168,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",171-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39288.71,,,39288.71,15793.43012,39288.7128,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",171-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45050.29,,,45050.29,17834.56427,45050.2908,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",171-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,57658.27,,,57658.27,22882.9694,61945.1428,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",171-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85751.28,,,85751.28,39432.23768,123641.5016,case rate,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,174-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48872.18,,,48872.18,13742.39956,48872.1792,case rate,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,174-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53031.51,,,53031.51,16797.91553,53031.5136,case rate,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,174-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65057.09,,,65057.09,22014.5596,65057.0892,case rate,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,174-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,90917.95,,,90917.95,33365.73957,90917.9508,case rate,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,175-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49214.62,,,49214.62,18256.39866,49214.6244,case rate,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,175-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55626.1,,,55626.1,22254.54749,55626.0984,case rate,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,175-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,68651.51,,,68651.51,29002.6607,68651.514,case rate,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,175-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100461.42,,,100461.42,51064.22823,101808.6324,case rate,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",176-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40633.5,,,40633.5,10411.02122,40633.4976,case rate,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",176-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48204.79,,,48204.79,17778.89697,54740.7728,case rate,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",176-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74680.55,,,74680.55,31694.48367,74680.5492,case rate,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",176-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,123690.21,,,123690.21,71004.2533,123690.2064,case rate,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29112.84,,,29112.84,10907.07867,29112.8412,case rate,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42025.77,,,42025.77,15745.18513,42025.7748,case rate,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56468.46,,,56468.46,21154.80915,56468.4636,case rate,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77912.53,,,77912.53,29189.4554,131328.9272,case rate,
EXTERNAL HEART ASSIST SYSTEMS,178-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,120528.21,,,120528.21,64325.41495,120528.2124,case rate,
EXTERNAL HEART ASSIST SYSTEMS,178-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,135133.38,,,135133.38,72120.0733,135133.3752,case rate,
EXTERNAL HEART ASSIST SYSTEMS,178-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145041.79,,,145041.79,77408.46633,145041.7896,case rate,
EXTERNAL HEART ASSIST SYSTEMS,178-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,196056.13,,,196056.13,104634.7218,196056.126,case rate,
DEFIBRILLATOR IMPLANTS,179-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83736.6,,,83736.6,40680.42214,83736.6,case rate,
DEFIBRILLATOR IMPLANTS,179-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94894.81,,,94894.81,45888.40685,94894.8144,case rate,
DEFIBRILLATOR IMPLANTS,179-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,116468.86,,,116468.86,63212.06905,116468.862,case rate,
DEFIBRILLATOR IMPLANTS,179-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,159731.94,,,159731.94,87251.68113,159731.9388,case rate,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28537.93,,,28537.93,12224.53798,28537.9332,case rate,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35626.8,,,35626.8,14166.70805,35626.7988,case rate,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49227.12,,,49227.12,23586.85142,50161.074,case rate,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,90608,,,90608,48915.47064,99909.5812,case rate,
LOWER EXTREMITY ARTERIAL PROCEDURES,181-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37601.48,,,37601.48,16844.92347,37601.4828,case rate,
LOWER EXTREMITY ARTERIAL PROCEDURES,181-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51964.18,,,51964.18,21978.68512,51964.1844,case rate,
LOWER EXTREMITY ARTERIAL PROCEDURES,181-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,80757.08,,,80757.08,34020.13955,84800.0996,case rate,
LOWER EXTREMITY ARTERIAL PROCEDURES,181-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,125907.35,,,125907.35,57610.70212,137173.278,case rate,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,182-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45442.73,,,45442.73,19284.38804,45442.728,case rate,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,182-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49347.1,,,49347.1,21353.97436,49347.1032,case rate,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,182-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59720.44,,,59720.44,27374.70158,66839.968,case rate,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,182-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106970.38,,,106970.38,54109.84779,130031.104,case rate,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,183-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98121.8,,,98121.8,50291.07135,98121.798,case rate,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,183-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100933.85,,,100933.85,52831.97411,100933.848,case rate,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,183-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,117523.69,,,117523.69,65177.74309,117523.6932,case rate,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,183-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,167303.23,,,167303.23,88037.20852,167303.2272,case rate,
ACUTE MYOCARDIAL INFARCTION,190-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18979.46,,,18979.46,4908.618368,18979.4628,case rate,
ACUTE MYOCARDIAL INFARCTION,190-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20691.69,,,20691.69,6489.569546,20691.6888,case rate,
ACUTE MYOCARDIAL INFARCTION,190-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26498.26,,,26498.26,9506.736935,30077.9856,case rate,
ACUTE MYOCARDIAL INFARCTION,190-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38451.35,,,38451.35,15969.09136,58323.2624,case rate,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,191-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22648.88,,,22648.88,6754.29846,22648.8756,case rate,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,191-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26550.75,,,26550.75,8429.265514,26550.7512,case rate,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,191-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34479.48,,,34479.48,11964.75727,34479.4824,case rate,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,191-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49447.09,,,49447.09,23082.13461,70774.2145,case rate,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,192-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24296.11,,,24296.11,7564.566865,24296.112,case rate,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,192-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30232.66,,,30232.66,11895.48242,30232.662,case rate,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,192-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42398.22,,,42398.22,20402.68214,42398.2152,case rate,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,192-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65884.46,,,65884.46,34344.24691,85359.8636,case rate,
ACUTE AND SUBACUTE ENDOCARDITIS,193-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18447.05,,,18447.05,7518.795978,21391.2776,case rate,
ACUTE AND SUBACUTE ENDOCARDITIS,193-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27173.15,,,27173.15,11648.07222,28570.7692,case rate,
ACUTE AND SUBACUTE ENDOCARDITIS,193-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35991.74,,,35991.74,15821.88229,44640.1424,case rate,
ACUTE AND SUBACUTE ENDOCARDITIS,193-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55933.55,,,55933.55,19017.18502,92551.7944,case rate,
HEART FAILURE,194-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12637.98,,,12637.98,5170.87318,12637.9776,case rate,
HEART FAILURE,194-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16587.35,,,16587.35,7424.780102,16587.3456,case rate,
HEART FAILURE,194-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22943.83,,,22943.83,10382.56904,26820.9884,case rate,
HEART FAILURE,194-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34779.43,,,34779.43,16741.01118,59882.3088,case rate,
CARDIAC ARREST AND SHOCK,196-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9076.05,,,9076.05,5052.116284,12142.7324,case rate,
CARDIAC ARREST AND SHOCK,196-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13425.35,,,13425.35,6543.99979,13425.3516,case rate,
CARDIAC ARREST AND SHOCK,196-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20909.15,,,20909.15,9109.643564,20909.154,case rate,
CARDIAC ARREST AND SHOCK,196-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37603.98,,,37603.98,18825.44212,43346.4656,case rate,
PERIPHERAL AND OTHER VASCULAR DISORDERS,197-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11608.14,,,11608.14,5903.207372,12148.952,case rate,
PERIPHERAL AND OTHER VASCULAR DISORDERS,197-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15505.02,,,15505.02,6915.11509,16425.9636,case rate,
PERIPHERAL AND OTHER VASCULAR DISORDERS,197-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21441.57,,,21441.57,9851.874164,24482.4188,case rate,
PERIPHERAL AND OTHER VASCULAR DISORDERS,197-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39071.25,,,39071.25,22813.69454,59374.3748,case rate,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,198-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11513.16,,,11513.16,4095.875861,11513.1576,case rate,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,198-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13757.8,,,13757.8,4888.825552,13757.7984,case rate,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,198-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18152.1,,,18152.1,6854.499591,18152.0952,case rate,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,198-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31559.95,,,31559.95,17462.21192,50185.9524,case rate,
HYPERTENSION,199-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12285.53,,,12285.53,4050.104974,12285.534,case rate,
HYPERTENSION,199-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15012.6,,,15012.6,5675.589988,15012.5976,case rate,
HYPERTENSION,199-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20679.19,,,20679.19,10229.17472,20679.1908,case rate,
HYPERTENSION,199-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30197.67,,,30197.67,16997.08074,50924.0116,case rate,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,200-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10543.31,,,10543.31,4220.818012,12210.83862,case rate,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,200-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15610,,,15610,6976.96764,15610.002,case rate,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,200-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22573.89,,,22573.89,11180.46694,25948.1712,case rate,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,200-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35029.39,,,35029.39,20948.22163,81673.714,case rate,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,201-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10910.75,,,10910.75,4022.889852,10910.754,case rate,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,201-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14145.24,,,14145.24,5311.896994,14145.2364,case rate,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,201-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21126.62,,,21126.62,9129.43638,22492.1468,case rate,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,201-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34699.45,,,34699.45,15520.04185,52659.28,case rate,
CHEST PAIN,203-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11663.13,,,11663.13,3613.425971,11899.87798,case rate,
CHEST PAIN,203-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13795.29,,,13795.29,4734.194177,13795.2924,case rate,
CHEST PAIN,203-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17194.75,,,17194.75,7037.583139,17194.7484,case rate,
CHEST PAIN,203-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25535.91,,,25535.91,16674.21043,48828.0064,case rate,
SYNCOPE AND COLLAPSE,204-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13440.35,,,13440.35,4154.017258,13440.3492,case rate,
SYNCOPE AND COLLAPSE,204-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15799.97,,,15799.97,5446.735553,15799.9716,case rate,
SYNCOPE AND COLLAPSE,204-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20356.74,,,20356.74,7779.813739,20356.7424,case rate,
SYNCOPE AND COLLAPSE,204-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31897.4,,,31897.4,14922.54621,43966.3524,case rate,
CARDIOMYOPATHY,205-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12070.57,,,12070.57,5577.862959,12182.1232,case rate,
CARDIOMYOPATHY,205-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15040.09,,,15040.09,7204.585024,15472.2916,case rate,
CARDIOMYOPATHY,205-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22263.94,,,22263.94,9117.06587,30131.8888,case rate,
CARDIOMYOPATHY,205-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40016.1,,,40016.1,20627.82543,51189.07935,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",206-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15470.02,,,15470.02,8209.070436,16381.76726,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",206-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15774.98,,,15774.98,8331.538485,16672.44786,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",206-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23651.22,,,23651.22,13368.81016,25794.7544,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",206-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46837.5,,,46837.5,21965.07756,70582.094,case rate,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12897.94,,,12897.94,4987.789632,12897.936,case rate,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16159.91,,,16159.91,7229.326044,16159.914,case rate,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22476.4,,,22476.4,10315.76829,24938.5228,case rate,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38086.41,,,38086.41,19013.47387,52389.764,case rate,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",220-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34484.48,,,34484.48,11795.28129,34484.4816,case rate,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",220-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49487.08,,,49487.08,20573.39518,49487.0808,case rate,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",220-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75362.94,,,75362.94,39021.53674,75362.94,case rate,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",220-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,134603.46,,,134603.46,106277.5255,146942.1964,case rate,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",222-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18402.06,,,18402.06,9287.778908,18402.0552,case rate,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",222-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31047.53,,,31047.53,15192.22333,31047.5316,case rate,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",222-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46377.58,,,46377.58,25201.20297,46377.5784,case rate,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",222-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98874.18,,,98874.18,58294.79132,114730.888,case rate,
OTHER SMALL AND LARGE BOWEL PROCEDURES,223-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25325.95,,,25325.95,10002.79439,25325.9472,case rate,
OTHER SMALL AND LARGE BOWEL PROCEDURES,223-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38313.87,,,38313.87,15392.62559,38313.8688,case rate,
OTHER SMALL AND LARGE BOWEL PROCEDURES,223-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53848.88,,,53848.88,20923.48061,55153.3396,case rate,
OTHER SMALL AND LARGE BOWEL PROCEDURES,223-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95029.79,,,95029.79,37913.13905,115653.462,case rate,
PERITONEAL ADHESIOLYSIS,224-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30657.59,,,30657.59,11619.62004,30657.594,case rate,
PERITONEAL ADHESIOLYSIS,224-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37911.43,,,37911.43,15476.74506,37911.4332,case rate,
PERITONEAL ADHESIOLYSIS,224-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53868.88,,,53868.88,20085.99709,55018.5816,case rate,
PERITONEAL ADHESIOLYSIS,224-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,92290.23,,,92290.23,39683.35903,115448.2152,case rate,
ANAL AND PERINEAL PROCEDURES,226-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20286.75,,,20286.75,8456.480636,20286.7536,case rate,
ANAL AND PERINEAL PROCEDURES,226-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26843.2,,,26843.2,12622.8684,26843.2044,case rate,
ANAL AND PERINEAL PROCEDURES,226-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39381.2,,,39381.2,16980.99908,39381.198,case rate,
ANAL AND PERINEAL PROCEDURES,226-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65829.47,,,65829.47,40645.78471,80996.23441,case rate,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",227-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28880.38,,,28880.38,10607.71233,28880.3784,case rate,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",227-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36129.22,,,36129.22,14005.89142,36129.2184,case rate,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",227-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51061.83,,,51061.83,21309.44053,51061.8288,case rate,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",227-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93020.11,,,93020.11,45345.34146,109334.3484,case rate,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",228-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21943.99,,,21943.99,7252.830013,21943.9884,case rate,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",228-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28295.47,,,28295.47,9181.392522,28295.472,case rate,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",228-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38531.33,,,38531.33,13930.43131,38531.334,case rate,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",228-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,66286.89,,,66286.89,31251.61941,92377.6456,case rate,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,229-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27510.6,,,27510.6,11359.83933,27510.5976,case rate,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,229-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37928.93,,,37928.93,16394.6369,37928.9304,case rate,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,229-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,57270.84,,,57270.84,27792.82482,57270.8352,case rate,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,229-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98826.69,,,98826.69,51088.96925,119971.9376,case rate,
MAJOR SMALL BOWEL PROCEDURES,230-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32292.33,,,32292.33,12657.50583,32292.3324,case rate,
MAJOR SMALL BOWEL PROCEDURES,230-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44277.91,,,44277.91,18604.00999,44277.9144,case rate,
MAJOR SMALL BOWEL PROCEDURES,230-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65572.01,,,65572.01,29179.55899,65572.0068,case rate,
MAJOR SMALL BOWEL PROCEDURES,230-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,120643.19,,,120643.19,62337.47399,120643.194,case rate,
MAJOR LARGE BOWEL PROCEDURES,231-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36886.6,,,36886.6,12823.27067,36886.5972,case rate,
MAJOR LARGE BOWEL PROCEDURES,231-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45292.75,,,45292.75,16192.99759,45292.752,case rate,
MAJOR LARGE BOWEL PROCEDURES,231-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64742.14,,,64742.14,25410.26459,64742.1396,case rate,
MAJOR LARGE BOWEL PROCEDURES,231-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106150.51,,,106150.51,40468.88641,106150.5132,case rate,
GASTRIC FUNDOPLICATION,232-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27970.52,,,27970.52,10726.46922,27970.524,case rate,
GASTRIC FUNDOPLICATION,232-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34167.03,,,34167.03,14103.61845,34167.0324,case rate,
GASTRIC FUNDOPLICATION,232-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45162.77,,,45162.77,28437.32839,45162.7728,case rate,
GASTRIC FUNDOPLICATION,232-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,99109.14,,,99109.14,68648.90819,138188.2062,case rate,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,233-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25008.5,,,25008.5,9552.507822,25008.498,case rate,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,233-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32299.83,,,32299.83,12073.61776,32299.8312,case rate,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,233-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46805.01,,,46805.01,19088.93398,46805.01,case rate,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,233-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70018.8,,,70018.8,38855.77191,72264.54966,case rate,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,234-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20281.75,,,20281.75,6547.710943,20281.7544,case rate,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,234-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26195.81,,,26195.81,8606.163807,26195.808,case rate,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,234-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38513.84,,,38513.84,12460.81472,38513.8368,case rate,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,234-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65592,,,65592,37529.65324,65592.0036,case rate,
DIGESTIVE MALIGNANCY,240-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17452.21,,,17452.21,8009.905225,17452.2072,case rate,
DIGESTIVE MALIGNANCY,240-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20171.77,,,20171.77,9018.10179,20171.772,case rate,
DIGESTIVE MALIGNANCY,240-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27508.1,,,27508.1,13940.32772,32827.0488,case rate,
DIGESTIVE MALIGNANCY,240-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45217.76,,,45217.76,27582.52615,61654.8948,case rate,
PEPTIC ULCER AND GASTRITIS,241-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14755.14,,,14755.14,5443.0244,14755.1388,case rate,
PEPTIC ULCER AND GASTRITIS,241-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18367.06,,,18367.06,7158.814137,18367.0608,case rate,
PEPTIC ULCER AND GASTRITIS,241-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26773.22,,,26773.22,11687.65785,26773.2156,case rate,
PEPTIC ULCER AND GASTRITIS,241-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52146.66,,,52146.66,26657.212,64884.9404,case rate,
MAJOR ESOPHAGEAL DISORDERS,242-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13460.35,,,13460.35,4658.734066,13460.346,case rate,
MAJOR ESOPHAGEAL DISORDERS,242-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17412.21,,,17412.21,6976.96764,17412.2136,case rate,
MAJOR ESOPHAGEAL DISORDERS,242-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24971,,,24971,10997.38339,25879.7556,case rate,
MAJOR ESOPHAGEAL DISORDERS,242-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51244.3,,,51244.3,26074.56098,65413.6064,case rate,
OTHER ESOPHAGEAL DISORDERS,243-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12677.97,,,12677.97,5304.474688,12677.9712,case rate,
OTHER ESOPHAGEAL DISORDERS,243-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16302.39,,,16302.39,6915.11509,16302.3912,case rate,
OTHER ESOPHAGEAL DISORDERS,243-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23763.7,,,23763.7,11024.59851,23763.6972,case rate,
OTHER ESOPHAGEAL DISORDERS,243-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42805.65,,,42805.65,22461.13501,47656.6484,case rate,
DIVERTICULITIS AND DIVERTICULOSIS,244-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12745.46,,,12745.46,4678.526882,12745.4604,case rate,
DIVERTICULITIS AND DIVERTICULOSIS,244-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16652.34,,,16652.34,6540.288637,16652.3352,case rate,
DIVERTICULITIS AND DIVERTICULOSIS,244-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25178.47,,,25178.47,10845.22612,25178.4708,case rate,
DIVERTICULITIS AND DIVERTICULOSIS,244-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43100.6,,,43100.6,19779.20844,63707.3628,case rate,
INFLAMMATORY BOWEL DISEASE,245-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13647.82,,,13647.82,6521.732872,13647.816,case rate,
INFLAMMATORY BOWEL DISEASE,245-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17404.71,,,17404.71,8877.077976,17404.7148,case rate,
INFLAMMATORY BOWEL DISEASE,245-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24968.5,,,24968.5,13804.25211,25253.6492,case rate,
INFLAMMATORY BOWEL DISEASE,245-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43628.02,,,43628.02,24630.92246,50686.58497,case rate,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14457.69,,,14457.69,4878.929144,14457.6864,case rate,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18297.07,,,18297.07,6376.997905,18297.072,case rate,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25863.36,,,25863.36,9554.981924,26800.2564,case rate,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37386.52,,,37386.52,21514.79099,59117.298,case rate,
INTESTINAL OBSTRUCTION,247-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11575.65,,,11575.65,4421.220274,11575.6476,case rate,
INTESTINAL OBSTRUCTION,247-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14997.6,,,14997.6,6002.171452,14997.6,case rate,
INTESTINAL OBSTRUCTION,247-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22418.91,,,22418.91,10741.31383,24967.5476,case rate,
INTESTINAL OBSTRUCTION,247-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41358.38,,,41358.38,21418.30101,52984.7724,case rate,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,248-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12750.46,,,12750.46,5063.249743,12750.4596,case rate,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,248-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16787.31,,,16787.31,7340.660634,17547.5648,case rate,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,248-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24661.05,,,24661.05,11489.72969,27343.4348,case rate,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,248-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44825.33,,,44825.33,19904.15059,67099.118,case rate,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",249-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10815.77,,,10815.77,4322.256194,10815.7692,case rate,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",249-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13520.34,,,13520.34,5654.560121,13520.3364,case rate,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",249-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19554.37,,,19554.37,9362.001968,19554.3708,case rate,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",249-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35991.74,,,35991.74,19865.80201,41934.6164,case rate,
ABDOMINAL PAIN,251-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11383.18,,,11383.18,5001.397193,11383.1784,case rate,
ABDOMINAL PAIN,251-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14700.15,,,14700.15,5901.970321,14700.1476,case rate,
ABDOMINAL PAIN,251-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19404.39,,,19404.39,8885.737333,19404.3948,case rate,
ABDOMINAL PAIN,251-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32794.75,,,32794.75,13706.52508,40143.3716,case rate,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",252-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13850.28,,,13850.28,7087.065179,13850.2836,case rate,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",252-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17144.76,,,17144.76,8288.2417,17144.7564,case rate,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",252-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24371.1,,,24371.1,13444.27027,25749.144,case rate,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",252-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46375.08,,,46375.08,33788.81101,58758.6344,case rate,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13917.77,,,13917.77,5614.974489,13917.7728,case rate,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17984.62,,,17984.62,7647.449282,17984.622,case rate,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25325.95,,,25325.95,11075.3176,27712.4644,case rate,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43625.52,,,43625.52,20257.94718,49049.8388,case rate,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11923.09,,,11923.09,5711.464467,11923.092,case rate,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16644.84,,,16644.84,7617.760058,16644.8364,case rate,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23933.67,,,23933.67,12753.99581,25139.6232,case rate,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42055.77,,,42055.77,23382.738,54071.1292,case rate,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",260-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42770.66,,,42770.66,18315.77711,42770.6556,case rate,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",260-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54218.82,,,54218.82,22749.36789,54218.8236,case rate,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",260-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74310.61,,,74310.61,33478.31121,74310.6084,case rate,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",260-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140300.05,,,140300.05,68009.35283,153966.198,case rate,
MAJOR BILIARY TRACT PROCEDURES,261-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35706.79,,,35706.79,17556.22779,35706.786,case rate,
MAJOR BILIARY TRACT PROCEDURES,261-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46730.02,,,46730.02,20447.21598,46730.022,case rate,
MAJOR BILIARY TRACT PROCEDURES,261-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64744.64,,,64744.64,28839.36996,64744.6392,case rate,
MAJOR BILIARY TRACT PROCEDURES,261-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,123320.27,,,123320.27,56363.75471,127306.9192,case rate,
CHOLECYSTECTOMY,263-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26193.31,,,26193.31,9202.422389,26193.3084,case rate,
CHOLECYSTECTOMY,263-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33202.19,,,33202.19,11789.09603,33202.1868,case rate,
CHOLECYSTECTOMY,263-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42120.76,,,42120.76,16421.85203,42120.7596,case rate,
CHOLECYSTECTOMY,263-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77732.56,,,77732.56,34638.66505,77732.5608,case rate,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",264-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32412.31,,,32412.31,14046.71411,32412.3132,case rate,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",264-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35461.83,,,35461.83,16510.9197,35461.8252,case rate,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",264-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51539.25,,,51539.25,23031.41552,59220.958,case rate,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",264-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,109539.97,,,109539.97,61248.86911,127597.1672,case rate,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,279-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12178.05,,,12178.05,5034.79757,12178.0512,case rate,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,279-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14947.61,,,14947.61,7568.278018,16218.6436,case rate,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,279-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22873.84,,,22873.84,11967.23137,28147.8364,case rate,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,279-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47754.86,,,47754.86,27713.65355,76812.06,case rate,
ALCOHOLIC LIVER DISEASE,280-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12535.49,,,12535.49,5038.508723,12535.494,case rate,
ALCOHOLIC LIVER DISEASE,280-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16174.91,,,16174.91,6806.254602,16174.9116,case rate,
ALCOHOLIC LIVER DISEASE,280-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24631.06,,,24631.06,12098.35878,26271.5904,case rate,
ALCOHOLIC LIVER DISEASE,280-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51804.21,,,51804.21,27156.9806,70743.8036,case rate,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,281-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15220.06,,,15220.06,7709.301832,15295.65834,case rate,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,281-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20184.27,,,20184.27,9416.432212,20184.27,case rate,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,281-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26265.8,,,26265.8,13007.59127,28570.7692,case rate,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,281-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38616.32,,,38616.32,20094.65644,50140.342,case rate,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12850.44,,,12850.44,4971.707969,12850.4436,case rate,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16732.32,,,16732.32,7026.44968,16732.3224,case rate,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25470.92,,,25470.92,11528.07827,28234.9108,case rate,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56403.47,,,56403.47,29874.78165,71666.3776,case rate,
OTHER DISORDERS OF THE LIVER,283-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12145.56,,,12145.56,6150.617572,12145.5564,case rate,
OTHER DISORDERS OF THE LIVER,283-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15542.51,,,15542.51,7450.758173,15542.5128,case rate,
OTHER DISORDERS OF THE LIVER,283-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22616.38,,,22616.38,10999.85749,24971.694,case rate,
OTHER DISORDERS OF THE LIVER,283-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42405.71,,,42405.71,23408.71607,53689.6604,case rate,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,284-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15552.51,,,15552.51,6745.639103,15552.5112,case rate,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,284-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20541.71,,,20541.71,9157.888553,20541.7128,case rate,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,284-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28450.45,,,28450.45,13476.43359,28450.4472,case rate,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,284-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49377.1,,,49377.1,24994.61546,61453.7944,case rate,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,303-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101563.75,,,101563.75,46210.04011,101563.7472,case rate,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,303-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,121987.98,,,121987.98,74849.00781,121987.9788,case rate,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,303-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,167900.63,,,167900.63,89785.16158,167900.6316,case rate,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,303-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,221749.51,,,221749.51,132386.7239,225864.774,case rate,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,304-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,68644.02,,,68644.02,30469.80318,68644.0152,case rate,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,304-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81546.95,,,81546.95,37658.30654,81546.9504,case rate,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,304-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,115024.09,,,115024.09,49603.271,115024.0932,case rate,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,304-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,170202.76,,,170202.76,73919.98251,190365.3704,case rate,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25630.9,,,25630.9,12742.86235,28220.3984,case rate,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34177.03,,,34177.03,15330.77304,39745.3172,case rate,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51764.22,,,51764.22,23719.21587,70113.5508,case rate,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,96094.62,,,96094.62,48347.66423,130648.9176,case rate,
HIP AND FEMUR FRACTURE REPAIR,308-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34324.51,,,34324.51,12426.1773,34324.5072,case rate,
HIP AND FEMUR FRACTURE REPAIR,308-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40488.52,,,40488.52,15106.86681,40488.5208,case rate,
HIP AND FEMUR FRACTURE REPAIR,308-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51981.68,,,51981.68,19182.94986,56923.8524,case rate,
HIP AND FEMUR FRACTURE REPAIR,308-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75132.98,,,75132.98,29528.40737,119598.7616,case rate,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,309-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33297.17,,,33297.17,16540.60892,33297.1716,case rate,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,309-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44285.41,,,44285.41,21734.98607,44285.4132,case rate,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,309-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,62982.42,,,62982.42,28908.64482,62982.4212,case rate,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,309-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100746.38,,,100746.38,56593.8462,119107.4132,case rate,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,310-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27105.66,,,27105.66,10533.48927,27105.6624,case rate,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,310-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36544.15,,,36544.15,15069.75528,36544.152,case rate,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,310-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51141.82,,,51141.82,23419.84953,52762.94,case rate,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,310-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,87965.92,,,87965.92,48989.6937,141852.4904,case rate,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",312-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27550.59,,,27550.59,18913.27274,30354.69758,case rate,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",312-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44135.44,,,44135.44,26360.31976,46715.4156,case rate,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",312-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74548.07,,,74548.07,37950.25058,93868.2764,case rate,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",312-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,151185.81,,,151185.81,93185.81478,186635.6836,case rate,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,313-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31992.38,,,31992.38,13044.7028,31992.3804,case rate,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,313-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42118.26,,,42118.26,19132.23077,42118.26,case rate,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,313-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61450.17,,,61450.17,26401.14244,61450.1664,case rate,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,313-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95684.69,,,95684.69,49239.578,134162.9916,case rate,
FOOT AND TOE PROCEDURES,314-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27115.66,,,27115.66,11925.17164,27115.6608,case rate,
FOOT AND TOE PROCEDURES,314-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28865.38,,,28865.38,12198.55991,28865.3808,case rate,
FOOT AND TOE PROCEDURES,314-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38286.37,,,38286.37,16163.30837,42139.8632,case rate,
FOOT AND TOE PROCEDURES,314-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,69466.38,,,69466.38,30921.3268,79714.54,case rate,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",315-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23488.74,,,23488.74,11076.55465,23488.7412,case rate,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",315-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37593.98,,,37593.98,15271.3946,37593.984,case rate,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",315-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56016.04,,,56016.04,26054.76816,56016.036,case rate,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",315-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91082.92,,,91082.92,41354.61493,106425.6488,case rate,
HAND AND WRIST PROCEDURES,316-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19796.83,,,19796.83,10506.27414,19796.832,case rate,
HAND AND WRIST PROCEDURES,316-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26730.72,,,26730.72,13457.87783,26730.7224,case rate,
HAND AND WRIST PROCEDURES,316-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41250.9,,,41250.9,21581.59175,44223.4292,case rate,
HAND AND WRIST PROCEDURES,316-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75247.96,,,75247.96,43606.04775,78407.14905,case rate,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",317-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23246.28,,,23246.28,11239.84539,23246.28,case rate,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",317-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30067.69,,,30067.69,13519.73038,30067.6884,case rate,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",317-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46170.11,,,46170.11,21681.79288,54064.9096,case rate,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",317-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84321.51,,,84321.51,56003.77287,130984.776,case rate,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,320-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25820.87,,,25820.87,11227.47488,25820.868,case rate,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,320-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35774.28,,,35774.28,13892.08273,35774.2752,case rate,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,320-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52114.16,,,52114.16,22818.64275,52138.9068,case rate,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,320-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,88910.77,,,88910.77,40027.25921,103734.6352,case rate,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,321-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42785.65,,,42785.65,19325.21072,42785.6532,case rate,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,321-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51899.19,,,51899.19,22260.73275,51899.1948,case rate,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,321-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71441.07,,,71441.07,30257.03041,76762.3032,case rate,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,321-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,111692.13,,,111692.13,44892.58079,146454.9944,case rate,
SHOULDER AND ELBOW JOINT REPLACEMENT,322-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44342.9,,,44342.9,24056.9308,44342.904,case rate,
SHOULDER AND ELBOW JOINT REPLACEMENT,322-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48147.3,,,48147.3,26496.39537,48147.2952,case rate,
SHOULDER AND ELBOW JOINT REPLACEMENT,322-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63224.88,,,63224.88,27937.55978,63224.8824,case rate,
SHOULDER AND ELBOW JOINT REPLACEMENT,322-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84653.95,,,84653.95,46592.28886,84653.9532,case rate,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,323-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40945.95,,,40945.95,17302.63234,40945.9476,case rate,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,323-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45977.64,,,45977.64,19446.44172,45977.6424,case rate,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,323-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61192.71,,,61192.71,27206.46264,61192.7076,case rate,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,323-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85348.84,,,85348.84,39387.70384,85348.842,case rate,
ELECTIVE HIP JOINT REPLACEMENT,324-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36609.14,,,36609.14,18568.13551,36609.1416,case rate,
ELECTIVE HIP JOINT REPLACEMENT,324-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39883.62,,,39883.62,18912.03569,39883.6176,case rate,
ELECTIVE HIP JOINT REPLACEMENT,324-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53828.89,,,53828.89,25482.01355,53828.886,case rate,
ELECTIVE HIP JOINT REPLACEMENT,324-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85428.83,,,85428.83,33055.23977,85428.8292,case rate,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,325-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50876.86,,,50876.86,34109.20722,50876.8584,case rate,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,325-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59225.52,,,59225.52,35182.96749,59225.5224,case rate,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,325-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,78172.49,,,78172.49,37621.19501,78172.4904,case rate,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,325-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108820.09,,,108820.09,47781.09488,108820.086,case rate,
ELECTIVE KNEE JOINT REPLACEMENT,326-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36396.68,,,36396.68,16432.98548,36396.6756,case rate,
ELECTIVE KNEE JOINT REPLACEMENT,326-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38638.82,,,38638.82,17557.46484,38638.8168,case rate,
ELECTIVE KNEE JOINT REPLACEMENT,326-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54948.71,,,54948.71,27123.58023,54948.7068,case rate,
ELECTIVE KNEE JOINT REPLACEMENT,326-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72008.48,,,72008.48,30553.92265,72008.4768,case rate,
FRACTURE OF FEMUR,340-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11410.67,,,11410.67,5316.845198,11410.674,case rate,
FRACTURE OF FEMUR,340-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14185.23,,,14185.23,6034.334778,14680.3292,case rate,
FRACTURE OF FEMUR,340-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20226.76,,,20226.76,8849.862854,35316.962,case rate,
FRACTURE OF FEMUR,340-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29750.24,,,29750.24,16870.90154,48058.8492,case rate,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12260.54,,,12260.54,4732.957126,12260.538,case rate,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15037.59,,,15037.59,5737.442538,15037.5936,case rate,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19161.93,,,19161.93,7997.534715,19946.2572,case rate,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35751.78,,,35751.78,15281.291,45123.20171,case rate,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",342-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12295.53,,,12295.53,4844.291716,12295.5324,case rate,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",342-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16562.35,,,16562.35,5866.095842,16562.3496,case rate,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",342-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23083.81,,,23083.81,9358.290815,23083.806,case rate,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",342-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37916.43,,,37916.43,15367.88457,54869.3112,case rate,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,343-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18679.51,,,18679.51,7009.130966,18679.5108,case rate,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,343-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21953.99,,,21953.99,8775.639794,21953.9868,case rate,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,343-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32082.37,,,32082.37,17239.54274,44503.3112,case rate,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,343-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51949.19,,,51949.19,21617.46623,79855.5176,case rate,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",344-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16227.4,,,16227.4,7847.851544,16670.6012,case rate,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",344-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20586.71,,,20586.71,9243.245072,23837.6536,case rate,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",344-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29530.27,,,29530.27,13350.25439,36973.4488,case rate,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",344-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47417.41,,,47417.41,25700.97158,71168.8096,case rate,
CONNECTIVE TISSUE DISORDERS,346-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14757.64,,,14757.64,7701.879526,15165.458,case rate,
CONNECTIVE TISSUE DISORDERS,346-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19651.86,,,19651.86,9745.487778,19948.3304,case rate,
CONNECTIVE TISSUE DISORDERS,346-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29992.7,,,29992.7,16054.44788,34475.2428,case rate,
CONNECTIVE TISSUE DISORDERS,346-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,62262.54,,,62262.54,31037.60959,101058.134,case rate,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",347-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14497.68,,,14497.68,5435.602094,14497.68,case rate,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",347-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18282.07,,,18282.07,6772.854225,18282.0744,case rate,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",347-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24741.04,,,24741.04,9911.252612,24741.0408,case rate,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",347-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42653.17,,,42653.17,17676.22174,65415.6796,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",349-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12840.45,,,12840.45,5452.920808,12840.4452,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",349-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18182.09,,,18182.09,7583.12263,18227.5744,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",349-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26118.32,,,26118.32,12562.25291,32300.456,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",349-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46462.56,,,46462.56,18529.78693,74042.2648,case rate,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,351-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11600.64,,,11600.64,5078.094355,11600.6436,case rate,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,351-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14707.65,,,14707.65,6184.017949,14707.6464,case rate,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,351-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22768.86,,,22768.86,10279.89381,23939.2404,case rate,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,351-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39998.6,,,39998.6,17155.42327,63864.926,case rate,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,361-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33619.62,,,33619.62,14186.50087,33619.62,case rate,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,361-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41758.32,,,41758.32,18065.8928,41758.3176,case rate,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,361-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63677.31,,,63677.31,39833.0422,69240.7336,case rate,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,361-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128034.51,,,128034.51,86944.89248,199037.566,case rate,
MASTECTOMY PROCEDURES,362-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31032.53,,,31032.53,13186.96366,31032.534,case rate,
MASTECTOMY PROCEDURES,362-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44682.85,,,44682.85,21263.66964,44682.8496,case rate,
MASTECTOMY PROCEDURES,362-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52956.53,,,52956.53,31751.38802,57599.7156,case rate,
MASTECTOMY PROCEDURES,362-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94032.45,,,94032.45,60199.5084,98228.30879,case rate,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25605.9,,,25605.9,12076.09186,25605.9024,case rate,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47132.46,,,47132.46,22093.73086,47132.4576,case rate,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59822.93,,,59822.93,24995.85251,59822.9268,case rate,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75992.84,,,75992.84,47162.56938,86414.37621,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",364-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18327.07,,,18327.07,7727.857597,18327.0672,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",364-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25320.95,,,25320.95,10091.86206,25320.948,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",364-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40436.03,,,40436.03,19288.09919,41942.9092,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",364-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72275.93,,,72275.93,30685.05006,110072.4076,case rate,
SKIN ULCERS,380-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12827.95,,,12827.95,5143.658058,14232.518,case rate,
SKIN ULCERS,380-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16702.33,,,16702.33,7255.304115,17296.7076,case rate,
SKIN ULCERS,380-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24163.63,,,24163.63,10987.48698,26905.9896,case rate,
SKIN ULCERS,380-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42353.22,,,42353.22,22432.68283,51670.3636,case rate,
MAJOR SKIN DISORDERS,381-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9051.05,,,9051.05,5139.946905,12325.174,case rate,
MAJOR SKIN DISORDERS,381-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14912.61,,,14912.61,10814.29984,18256.5992,case rate,
MAJOR SKIN DISORDERS,381-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29982.7,,,29982.7,16178.15298,39952.6372,case rate,
MAJOR SKIN DISORDERS,381-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59035.55,,,59035.55,46947.3225,122376.8496,case rate,
MALIGNANT BREAST DISORDERS,382-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14382.7,,,14382.7,7409.93549,14382.6984,case rate,
MALIGNANT BREAST DISORDERS,382-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16937.29,,,16937.29,8736.054162,17551.24968,case rate,
MALIGNANT BREAST DISORDERS,382-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23988.66,,,23988.66,12394.01397,31224.4652,case rate,
MALIGNANT BREAST DISORDERS,382-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35526.81,,,35526.81,22958.42951,59992.1884,case rate,
CELLULITIS AND OTHER SKIN INFECTIONS,383-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10528.32,,,10528.32,4840.580563,10528.3152,case rate,
CELLULITIS AND OTHER SKIN INFECTIONS,383-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14430.19,,,14430.19,6415.346486,14430.1908,case rate,
CELLULITIS AND OTHER SKIN INFECTIONS,383-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21469.06,,,21469.06,9314.99403,24503.1508,case rate,
CELLULITIS AND OTHER SKIN INFECTIONS,383-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39218.72,,,39218.72,19870.75021,57916.9152,case rate,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",384-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13467.84,,,13467.84,4469.465263,13467.8448,case rate,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",384-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16879.8,,,16879.8,5931.659545,16879.7988,case rate,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",384-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24593.56,,,24593.56,9802.392124,24593.5644,case rate,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",384-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41223.4,,,41223.4,23002.96335,46957.76136,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",385-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10365.84,,,10365.84,5467.76542,10365.8412,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",385-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13672.81,,,13672.81,6529.155178,13672.812,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",385-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21229.1,,,21229.1,11117.37734,22452.756,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",385-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42590.68,,,42590.68,21545.71727,60012.9204,case rate,
ADRENAL PROCEDURES,401-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31822.41,,,31822.41,12116.91455,31822.4076,case rate,
ADRENAL PROCEDURES,401-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56076.03,,,56076.03,35069.1588,56076.0264,case rate,
ADRENAL PROCEDURES,401-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70371.24,,,70371.24,42096.84553,70371.2388,case rate,
ADRENAL PROCEDURES,401-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118153.59,,,118153.59,73754.21767,152983.7211,case rate,
PROCEDURES FOR OBESITY,403-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27653.07,,,27653.07,9434.987977,27653.0748,case rate,
PROCEDURES FOR OBESITY,403-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32104.86,,,32104.86,10330.6129,32104.8624,case rate,
PROCEDURES FOR OBESITY,403-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45797.67,,,45797.67,21879.72104,45797.6712,case rate,
PROCEDURES FOR OBESITY,403-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93542.53,,,93542.53,52066.23954,136348.1444,case rate,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",404-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22673.87,,,22673.87,8439.161922,22673.8716,case rate,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",404-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33262.18,,,33262.18,13549.4196,33262.1772,case rate,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",404-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55818.57,,,55818.57,24232.59204,55818.5676,case rate,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",404-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,116111.42,,,116111.42,55286.0244,116111.4192,case rate,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",405-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31882.4,,,31882.4,14101.14435,31882.398,case rate,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",405-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35949.25,,,35949.25,17777.65992,35949.2472,case rate,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",405-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54601.26,,,54601.26,34643.61326,61057.8132,case rate,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",405-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108352.66,,,108352.66,64833.84291,173902.0892,case rate,
DIABETES,420-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10585.81,,,10585.81,5450.446706,10585.806,case rate,
DIABETES,420-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13602.82,,,13602.82,6132.061807,13602.8232,case rate,
DIABETES,420-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20111.78,,,20111.78,9246.956225,20261.3836,case rate,
DIABETES,420-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39328.71,,,39328.71,19479.8421,52659.28,case rate,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",421-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9700.95,,,9700.95,6843.636573,12957.5,case rate,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",421-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14510.18,,,14510.18,10073.30629,18934.5356,case rate,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",421-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21988.98,,,21988.98,16778.12271,28767.7232,case rate,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",421-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42410.71,,,42410.71,28107.03577,66369.3516,case rate,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,422-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8221.18,,,8221.18,4104.535218,8221.1844,case rate,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,422-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12235.54,,,12235.54,5026.138213,12235.542,case rate,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,422-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17809.65,,,17809.65,8599.978552,18700.264,case rate,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,422-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31135.02,,,31135.02,13498.70051,47067.8596,case rate,
INBORN ERRORS OF METABOLISM,423-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12470.5,,,12470.5,7505.188417,17938.82382,case rate,
INBORN ERRORS OF METABOLISM,423-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16337.39,,,16337.39,12073.61776,22501.83327,case rate,
INBORN ERRORS OF METABOLISM,423-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25660.89,,,25660.89,21091.5376,33626.56297,case rate,
INBORN ERRORS OF METABOLISM,423-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55516.12,,,55516.12,55516.116,112746.8356,case rate,
OTHER ENDOCRINE DISORDERS,424-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11885.6,,,11885.6,5590.233469,11885.598,case rate,
OTHER ENDOCRINE DISORDERS,424-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16539.85,,,16539.85,7811.977065,16539.8532,case rate,
OTHER ENDOCRINE DISORDERS,424-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24321.11,,,24321.11,13841.36364,24573.6396,case rate,
OTHER ENDOCRINE DISORDERS,424-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42985.62,,,42985.62,17585.91702,57699.2292,case rate,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,425-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10568.31,,,10568.31,4443.487192,10568.3088,case rate,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,425-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12940.43,,,12940.43,5879.703403,12940.4292,case rate,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,425-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17514.7,,,17514.7,9494.366425,20698.8288,case rate,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,425-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34626.96,,,34626.96,16985.94728,51643.412,case rate,
NON-HYPOVOLEMIC SODIUM DISORDERS,426-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11280.69,,,11280.69,4412.560917,11280.6948,case rate,
NON-HYPOVOLEMIC SODIUM DISORDERS,426-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14942.61,,,14942.61,6490.806597,14942.6088,case rate,
NON-HYPOVOLEMIC SODIUM DISORDERS,426-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21841.5,,,21841.5,10221.75241,21841.5048,case rate,
NON-HYPOVOLEMIC SODIUM DISORDERS,426-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38723.8,,,38723.8,19425.41185,39606.92203,case rate,
THYROID DISORDERS,427-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11013.24,,,11013.24,4713.16431,11013.2376,case rate,
THYROID DISORDERS,427-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15192.57,,,15192.57,6583.585422,15192.5688,case rate,
THYROID DISORDERS,427-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24198.63,,,24198.63,12140.41851,24198.6276,case rate,
THYROID DISORDERS,427-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42263.24,,,42263.24,22892.86581,44505.67884,case rate,
KIDNEY TRANSPLANT,440-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106417.97,,,106417.97,76832.792,106417.9704,case rate,
KIDNEY TRANSPLANT,440-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,119178.43,,,119178.43,85811.75377,119178.4284,case rate,
KIDNEY TRANSPLANT,440-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,138957.76,,,138957.76,90276.27083,138957.7632,case rate,
KIDNEY TRANSPLANT,440-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,210811.26,,,210811.26,116025.4874,215283.1612,case rate,
MAJOR BLADDER PROCEDURES,441-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36241.7,,,36241.7,23355.52288,36241.7004,case rate,
MAJOR BLADDER PROCEDURES,441-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55153.67,,,55153.67,24085.38297,55153.674,case rate,
MAJOR BLADDER PROCEDURES,441-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72115.96,,,72115.96,29608.81569,72115.9596,case rate,
MAJOR BLADDER PROCEDURES,441-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,142082.26,,,142082.26,79176.2122,142082.2632,case rate,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,442-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33899.58,,,33899.58,11636.93876,33899.5752,case rate,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,442-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39366.2,,,39366.2,13346.54324,39366.2004,case rate,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,442-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,57193.35,,,57193.35,22750.60494,58375.0924,case rate,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,442-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100198.97,,,100198.97,44083.54944,132185.1588,case rate,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,443-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28535.43,,,28535.43,11062.94709,28535.4336,case rate,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,443-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33039.71,,,33039.71,12123.0998,33039.7128,case rate,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,443-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48587.22,,,48587.22,22086.30855,48587.2248,case rate,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,443-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81424.47,,,81424.47,37955.19878,105065.6296,case rate,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,444-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22443.91,,,22443.91,11144.59246,23252.19482,case rate,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,444-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33467.14,,,33467.14,17159.13442,36216.7308,case rate,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,444-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49377.1,,,49377.1,25838.28424,67018.2632,case rate,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,444-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84379,,,84379,48597.54854,128246.0788,case rate,
OTHER BLADDER PROCEDURES,445-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23348.76,,,23348.76,8854.811058,23348.7636,case rate,
OTHER BLADDER PROCEDURES,445-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29707.75,,,29707.75,12878.93796,29707.746,case rate,
OTHER BLADDER PROCEDURES,445-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41720.82,,,41720.82,21110.27532,41720.8236,case rate,
OTHER BLADDER PROCEDURES,445-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77910.03,,,77910.03,50785.1072,79405.37778,case rate,
URETHRAL AND TRANSURETHRAL PROCEDURES,446-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20209.27,,,20209.27,6557.607351,20209.266,case rate,
URETHRAL AND TRANSURETHRAL PROCEDURES,446-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24608.56,,,24608.56,8358.753607,24608.562,case rate,
URETHRAL AND TRANSURETHRAL PROCEDURES,446-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38683.81,,,38683.81,15461.90045,38683.8096,case rate,
URETHRAL AND TRANSURETHRAL PROCEDURES,446-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64114.74,,,64114.74,25928.58896,68185.4748,case rate,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",447-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30457.63,,,30457.63,17965.69167,30457.626,case rate,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",447-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36876.6,,,36876.6,19581.28028,36876.5988,case rate,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",447-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51471.76,,,51471.76,23259.0329,60769.6384,case rate,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",447-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,104930.71,,,104930.71,52201.0781,158197.5992,case rate,
KIDNEY AND URINARY TRACT MALIGNANCY,461-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15040.09,,,15040.09,6963.360079,16296.14042,case rate,
KIDNEY AND URINARY TRACT MALIGNANCY,461-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18139.6,,,18139.6,8693.994428,18328.65129,case rate,
KIDNEY AND URINARY TRACT MALIGNANCY,461-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26253.3,,,26253.3,13224.07519,31158.1228,case rate,
KIDNEY AND URINARY TRACT MALIGNANCY,461-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38003.92,,,38003.92,23208.31381,48266.1692,case rate,
NEPHRITIS AND NEPHROSIS,462-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10285.85,,,10285.85,6113.506042,12236.0264,case rate,
NEPHRITIS AND NEPHROSIS,462-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15020.1,,,15020.1,8983.464362,15020.0964,case rate,
NEPHRITIS AND NEPHROSIS,462-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27875.54,,,27875.54,17557.46484,29937.84867,case rate,
NEPHRITIS AND NEPHROSIS,462-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,62567.49,,,62567.49,42597.85119,83303.2492,case rate,
KIDNEY AND URINARY TRACT INFECTIONS,463-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11468.16,,,11468.16,4507.813844,11468.1648,case rate,
KIDNEY AND URINARY TRACT INFECTIONS,463-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14412.69,,,14412.69,5660.745376,14412.6936,case rate,
KIDNEY AND URINARY TRACT INFECTIONS,463-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19354.4,,,19354.4,8570.289328,20464.5572,case rate,
KIDNEY AND URINARY TRACT INFECTIONS,463-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30110.18,,,30110.18,15012.85094,45216.492,case rate,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12080.57,,,12080.57,4434.827835,12080.5668,case rate,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14842.62,,,14842.62,4939.544643,14842.6248,case rate,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24563.57,,,24563.57,10142.58115,24563.5692,case rate,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42668.17,,,42668.17,14394.32544,44967.708,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",466-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10365.84,,,10365.84,4913.566572,10413.6836,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",466-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14847.62,,,14847.62,5910.629678,14847.624,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",466-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21099.12,,,21099.12,9423.854518,24121.682,case rate,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",466-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35329.35,,,35329.35,16039.60327,48257.8764,case rate,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",468-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11188.21,,,11188.21,5075.620253,11188.2096,case rate,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",468-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15387.54,,,15387.54,6367.101497,15387.5376,case rate,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",468-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21968.98,,,21968.98,11291.80153,24658.6408,case rate,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",468-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38508.84,,,38508.84,28734.22063,58229.9684,case rate,
ACUTE KIDNEY INJURY,469-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11318.19,,,11318.19,4437.301937,11318.1888,case rate,
ACUTE KIDNEY INJURY,469-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14677.65,,,14677.65,5851.25123,15434.974,case rate,
ACUTE KIDNEY INJURY,469-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22908.83,,,22908.83,10456.7921,28158.2024,case rate,
ACUTE KIDNEY INJURY,469-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42860.64,,,42860.64,23649.94102,68442.5516,case rate,
CHRONIC KIDNEY DISEASE,470-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9463.49,,,9463.49,5408.386972,10507.31509,case rate,
CHRONIC KIDNEY DISEASE,470-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12887.94,,,12887.94,6814.913959,14166.1756,case rate,
CHRONIC KIDNEY DISEASE,470-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21296.59,,,21296.59,11987.02419,24714.6172,case rate,
CHRONIC KIDNEY DISEASE,470-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37301.53,,,37301.53,28924.72648,55068.3384,case rate,
MAJOR MALE PELVIC PROCEDURES,480-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31872.4,,,31872.4,10733.89153,31872.3996,case rate,
MAJOR MALE PELVIC PROCEDURES,480-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36631.64,,,36631.64,11931.3569,36631.638,case rate,
MAJOR MALE PELVIC PROCEDURES,480-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54628.76,,,54628.76,28808.44369,54628.758,case rate,
MAJOR MALE PELVIC PROCEDURES,480-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,89723.14,,,89723.14,53851.37,99928.78029,case rate,
TRANSURETHRAL PROSTATECTOMY,482-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17547.19,,,17547.19,6333.70112,17547.192,case rate,
TRANSURETHRAL PROSTATECTOMY,482-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21459.07,,,21459.07,7856.510901,21459.066,case rate,
TRANSURETHRAL PROSTATECTOMY,482-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39028.75,,,39028.75,15105.62976,48801.0548,case rate,
TRANSURETHRAL PROSTATECTOMY,482-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64947.11,,,64947.11,40045.81497,67897.58062,case rate,
"PENIS, TESTES AND SCROTAL PROCEDURES",483-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22598.88,,,22598.88,10968.93122,23008.83432,case rate,
"PENIS, TESTES AND SCROTAL PROCEDURES",483-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30185.17,,,30185.17,13637.25022,30185.1696,case rate,
"PENIS, TESTES AND SCROTAL PROCEDURES",483-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45367.74,,,45367.74,29367.59074,65958.858,case rate,
"PENIS, TESTES AND SCROTAL PROCEDURES",483-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81874.4,,,81874.4,61402.26344,102854.6324,case rate,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,484-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26938.19,,,26938.19,9928.571326,26938.1892,case rate,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,484-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34426.99,,,34426.99,10566.88964,34426.9908,case rate,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,484-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41285.89,,,41285.89,14999.24338,41285.8932,case rate,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,484-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91002.94,,,91002.94,44530.2628,93312.97992,case rate,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12078.07,,,12078.07,6494.51775,13909.85547,case rate,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16552.35,,,16552.35,9042.84281,19544.0564,case rate,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25508.42,,,25508.42,14146.91524,32750.3404,case rate,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45340.24,,,45340.24,30680.10185,45340.2444,case rate,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10988.24,,,10988.24,4676.05278,10988.2416,case rate,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14745.14,,,14745.14,6501.940056,14745.1404,case rate,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21649.04,,,21649.04,9456.017844,23275.8164,case rate,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44190.43,,,44190.43,24962.45213,44213.0632,case rate,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",510-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32867.24,,,32867.24,14689.98063,32867.2404,case rate,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",510-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38461.35,,,38461.35,18325.67351,38461.3452,case rate,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",510-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58620.62,,,58620.62,39320.90309,58620.6192,case rate,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",510-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,120598.2,,,120598.2,83533.10583,132877.6076,case rate,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,511-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33049.71,,,33049.71,13689.20637,33049.7112,case rate,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,511-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40136.08,,,40136.08,16269.69475,40136.0772,case rate,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,511-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59110.54,,,59110.54,24194.24346,59110.5408,case rate,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,511-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108867.58,,,108867.58,70245.94104,129085.7248,case rate,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,512-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30305.15,,,30305.15,11993.20945,30305.1504,case rate,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,512-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35854.26,,,35854.26,14775.33714,35854.2624,case rate,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,512-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56425.97,,,56425.97,20139.19028,56425.9704,case rate,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,512-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,96672.03,,,96672.03,66543.44739,155560.4888,case rate,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23416.25,,,23416.25,8623.482521,23416.2528,case rate,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28187.99,,,28187.99,11237.37128,28187.9892,case rate,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44782.83,,,44782.83,17451.07846,44782.8336,case rate,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72678.37,,,72678.37,48770.73568,99546.7712,case rate,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19391.9,,,19391.9,8475.036401,20611.7544,case rate,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28765.4,,,28765.4,13920.5349,28765.3968,case rate,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55523.61,,,55523.61,20611.7544,55523.6148,case rate,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,92800.15,,,92800.15,64279.64406,99535.28358,case rate,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16377.38,,,16377.38,8457.717687,16377.3792,case rate,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20789.17,,,20789.17,10204.4337,20789.1732,case rate,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34891.92,,,34891.92,17614.36919,42208.2788,case rate,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61375.18,,,61375.18,40275.90646,74713.92807,case rate,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,518-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19889.32,,,19889.32,8877.077976,19889.3172,case rate,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,518-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28867.88,,,28867.88,11375.921,28867.8804,case rate,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,518-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48549.73,,,48549.73,24019.81927,48604.50066,case rate,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,518-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,89040.75,,,89040.75,53627.3979,123933.8228,case rate,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,519-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22143.96,,,22143.96,8666.779306,22143.9564,case rate,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,519-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28140.5,,,28140.5,11551.58224,28140.4968,case rate,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,519-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45487.72,,,45487.72,24517.11377,45487.7208,case rate,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,519-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,87011.08,,,87011.08,55004.23566,125403.7216,case rate,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13037.91,,,13037.91,6657.808482,13587.62814,case rate,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17554.69,,,17554.69,9229.637511,17554.6908,case rate,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25523.42,,,25523.42,12299.99809,30100.7908,case rate,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40988.44,,,40988.44,16086.6112,51977.1972,case rate,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11913.09,,,11913.09,4797.283778,11913.0936,case rate,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15552.51,,,15552.51,6639.252717,15552.5112,case rate,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24013.66,,,24013.66,9031.709351,24028.388,case rate,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39301.21,,,39301.21,26913.28156,45870.35111,case rate,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9933.41,,,9933.41,4301.226327,9995.807368,case rate,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12453.01,,,12453.01,5490.032338,12453.0072,case rate,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19584.37,,,19584.37,8175.670059,20124.5524,case rate,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32392.32,,,32392.32,21329.0816,41303.68554,case rate,
CESAREAN SECTION WITH STERILIZATION,539-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16009.94,,,16009.94,8315.456822,16009.938,case rate,
CESAREAN SECTION WITH STERILIZATION,539-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18492.04,,,18492.04,9798.680971,18492.0408,case rate,
CESAREAN SECTION WITH STERILIZATION,539-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26135.82,,,26135.82,14766.67779,26135.8176,case rate,
CESAREAN SECTION WITH STERILIZATION,539-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54086.34,,,54086.34,27495.93258,54086.3448,case rate,
CESAREAN SECTION WITHOUT STERILIZATION,540-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15709.99,,,15709.99,8545.548308,16608.4052,case rate,
CESAREAN SECTION WITHOUT STERILIZATION,540-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19136.94,,,19136.94,10912.02687,19136.9376,case rate,
CESAREAN SECTION WITHOUT STERILIZATION,540-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24188.63,,,24188.63,14180.31561,24389.1248,case rate,
CESAREAN SECTION WITHOUT STERILIZATION,540-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40646,,,40646,14674.8,56092.4992,case rate,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,541-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16309.89,,,16309.89,8247.419017,16309.89,case rate,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,541-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16997.28,,,16997.28,9564.96,16997.28,case rate,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,541-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20924.15,,,20924.15,9564.96,20924.1516,case rate,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,541-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28138,,,28138,9564.96,28137.9972,case rate,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,542-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10700.79,,,10700.79,7415.735358,12337.6132,case rate,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,542-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12173.05,,,12173.05,8497.303319,14060.4424,case rate,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,542-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17957.13,,,17957.13,9564.96,25326.2112,case rate,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,542-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41235.9,,,41235.9,9564.96,41235.9012,case rate,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",543-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12498,,,12498,4687.186239,12498,case rate,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",543-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16544.85,,,16544.85,6346.07163,16544.8524,case rate,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",543-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22371.42,,,22371.42,12108.25519,22371.42,case rate,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",543-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60722.78,,,60722.78,37334.19918,60722.7828,case rate,
ANTEPARTUM WITH O.R. PROCEDURE,547-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16082.43,,,16082.43,7485.395601,16082.4264,case rate,
ANTEPARTUM WITH O.R. PROCEDURE,547-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22486.4,,,22486.4,9248.193276,22486.4016,case rate,
ANTEPARTUM WITH O.R. PROCEDURE,547-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33412.15,,,33412.15,15474.27096,33412.1532,case rate,
ANTEPARTUM WITH O.R. PROCEDURE,547-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59687.95,,,59687.95,39007.92918,60186.65798,case rate,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,548-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10853.26,,,10853.26,5402.201717,10853.2632,case rate,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,548-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22506.4,,,22506.4,10036.19476,22506.3984,case rate,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,548-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37598.98,,,37598.98,16562.87584,37598.9832,case rate,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,548-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85846.26,,,85846.26,45282.25186,85846.2624,case rate,
VAGINAL DELIVERY,560-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9281.01,,,9281.01,6405.450078,10977.594,case rate,
VAGINAL DELIVERY,560-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10598.3,,,10598.3,7140.828122,12132.3664,case rate,
VAGINAL DELIVERY,560-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13802.79,,,13802.79,9198.711236,15059.7248,case rate,
VAGINAL DELIVERY,560-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19436.89,,,19436.89,9564.96,35173.9112,case rate,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,561-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6518.96,,,6518.96,3781.664907,7857.428,case rate,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,561-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9898.42,,,9898.42,4975.419122,9898.416,case rate,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,561-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15482.52,,,15482.52,6473.487883,15482.5224,case rate,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,561-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32714.76,,,32714.76,14762.96663,34523.97624,case rate,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7981.22,,,7981.22,4097.112912,7981.2228,case rate,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10675.79,,,10675.79,4789.861472,10675.7916,case rate,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14905.11,,,14905.11,9176.444318,14905.1148,case rate,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39208.73,,,39208.73,15036.9196,49092.57713,case rate,
ANTEPARTUM WITHOUT O.R. PROCEDURE,566-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6281.49,,,6281.49,3870.732579,7063.3924,case rate,
ANTEPARTUM WITHOUT O.R. PROCEDURE,566-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8453.65,,,8453.65,5616.21154,9244.3988,case rate,
ANTEPARTUM WITHOUT O.R. PROCEDURE,566-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12300.53,,,12300.53,7637.552874,13602.2652,case rate,
ANTEPARTUM WITHOUT O.R. PROCEDURE,566-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27288.13,,,27288.13,13598.90164,35116.00202,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",580-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7308.83,,,7308.83,3106.94,7308.8304,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",580-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9346,,,9346,3106.94,9346.0044,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",580-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15332.55,,,15332.55,3106.94,15332.5464,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",580-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25140.98,,,25140.98,3106.94,25158.51877,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2544.59,,,2544.59,2088.142088,3106.94,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3811.89,,,3811.89,2351.633951,3852.0056,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5844.06,,,5844.06,2710.378741,5844.0648,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9778.44,,,9778.44,3106.94,10254.0472,case rate,
NEONATE WITH ECMO,583-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,374287.6,,,374287.6,3106.94,374287.6044,case rate,
NEONATE WITH ECMO,583-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,433113.19,,,433113.19,3106.94,433113.1908,case rate,
NEONATE WITH ECMO,583-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,587348.51,,,587348.51,3106.94,602569.6213,case rate,
NEONATE WITH ECMO,583-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,741583.83,,,741583.83,3106.94,741583.8276,case rate,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,588-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,252589.58,,,252589.58,3106.94,400220.894,case rate,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,588-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,383736.09,,,383736.09,3106.94,400220.894,case rate,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,588-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,391889.79,,,391889.79,3106.94,523155.4344,case rate,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,588-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,608300.16,,,608300.16,3106.94,608300.1564,case rate,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",589-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118848.48,,,118848.48,3106.94,284033.2549,case rate,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",589-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98661.71,,,98661.71,3106.94,275285.7968,case rate,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",589-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,78477.44,,,78477.44,3106.94,250260.225,case rate,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",589-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1664.73,,,1664.73,1664.7336,47416.99153,case rate,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,591-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3244.48,,,3244.48,2247.721667,214623.6845,case rate,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,591-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,119430.89,,,119430.89,3106.94,297672.7098,case rate,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,591-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,224441.58,,,224441.58,3106.94,316172.6148,case rate,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,591-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,383106.19,,,383106.19,3106.94,453416.6724,case rate,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,593-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3744.4,,,3744.4,2595.332998,223963.6496,case rate,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,593-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,202207.64,,,202207.64,3106.94,243214.037,case rate,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,593-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255121.67,,,255121.67,3106.94,282328.376,case rate,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,593-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,396726.51,,,396726.51,3106.94,396726.5136,case rate,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,602-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33644.62,,,33644.62,3106.94,134606.6564,case rate,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,602-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171100.12,,,171100.12,3106.94,196622.288,case rate,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,602-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,224236.62,,,224236.62,3106.94,231412.6572,case rate,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,602-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,284374.49,,,284374.49,3106.94,313501.0112,case rate,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,603-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3716.91,,,3716.91,3035.723154,107271.5144,case rate,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,603-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76567.75,,,76567.75,3106.94,143019.702,case rate,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,603-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,155187.67,,,155187.67,3106.94,186808.4802,case rate,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,603-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,318901.47,,,318901.47,3106.94,318901.4676,case rate,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,607-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54461.28,,,54461.28,3106.94,125246.1584,case rate,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,607-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,131576.44,,,131576.44,3106.94,155042.1888,case rate,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,607-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,169922.81,,,169922.81,3106.94,189679.1412,case rate,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,607-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,218425.05,,,218425.05,3106.94,256779.1318,case rate,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,608-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13172.89,,,13172.89,3106.94,87994.9008,case rate,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,608-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,97231.94,,,97231.94,3106.94,117882.152,case rate,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,608-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,131711.42,,,131711.42,3106.94,141466.8752,case rate,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,608-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,138297.87,,,138297.87,3106.94,235257.5006,case rate,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,609-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85576.31,,,85576.31,3106.94,115776.5064,case rate,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,609-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,90080.58,,,90080.58,3106.94,119983.4885,case rate,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,609-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,189647.15,,,189647.15,3106.94,191851.4507,case rate,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,609-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,380661.58,,,380661.58,3106.94,430881.039,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,611-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27863.04,,,27863.04,3106.94,51933.66,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,611-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61925.09,,,61925.09,3106.94,83651.5468,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,611-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108112.7,,,108112.7,3106.94,129902.5656,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,611-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165985.94,,,165985.94,3106.94,216541.2751,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,612-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56503.46,,,56503.46,3106.94,72939.3224,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,612-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,86443.67,,,86443.67,3106.94,94332.6732,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,612-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,111627.14,,,111627.14,3106.94,131503.076,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,612-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,158724.6,,,158724.6,3106.94,175674.6752,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,613-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34761.94,,,34761.94,3106.94,55232.1212,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,613-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63089.9,,,63089.9,3106.94,83500.2032,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,613-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101548.75,,,101548.75,3106.94,109408.5733,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,613-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,155727.58,,,155727.58,3106.94,182804.2986,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,614-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21714.03,,,21714.03,3106.94,41352.0472,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,614-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52746.56,,,52746.56,3106.94,68380.3556,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,614-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,96004.64,,,96004.64,3106.94,104408.4252,case rate,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,614-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,125144.97,,,125144.97,3106.94,156676.8445,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,621-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9923.41,,,9923.41,3106.94,22326.0729,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,621-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32142.36,,,32142.36,3106.94,53971.95178,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,621-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76437.77,,,76437.77,3106.94,99259.5389,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,621-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,130219.16,,,130219.16,3106.94,182153.0839,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,622-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35289.35,,,35289.35,3106.94,40164.1036,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,622-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52781.55,,,52781.55,3106.94,54533.4528,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,622-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59857.92,,,59857.92,3106.94,74755.4456,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,622-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,102781.05,,,102781.05,3106.94,128510.1195,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,623-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21794.01,,,21794.01,3106.94,30162.9868,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,623-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35351.84,,,35351.84,3106.94,45294.34714,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,623-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77785.05,,,77785.05,3106.94,81926.863,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,623-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94327.41,,,94327.41,3106.94,128086.4919,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,625-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25183.47,,,25183.47,3106.94,33167.0536,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,625-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34244.52,,,34244.52,3106.94,53639.9036,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,625-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61932.59,,,61932.59,3106.94,72902.24431,case rate,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,625-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,86898.59,,,86898.59,3106.94,136351.7357,case rate,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",626-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3811.89,,,3811.89,2371.426767,4318.4756,case rate,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",626-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4446.79,,,4446.79,3106.94,8636.9512,case rate,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",626-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10528.32,,,10528.32,3106.94,27737.3428,case rate,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",626-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58003.22,,,58003.22,3106.94,63318.7978,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,630-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53693.91,,,53693.91,3106.94,71500.5216,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,630-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,135353.34,,,135353.34,3106.94,135353.34,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,630-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,213335.86,,,213335.86,3106.94,213335.8608,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,630-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441526.84,,,441526.84,3106.94,441526.8444,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,631-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11115.72,,,11115.72,3106.94,37594.69119,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,631-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,86071.23,,,86071.23,3106.94,86071.2264,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,631-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140342.54,,,140342.54,3106.94,140342.5416,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,631-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,365451.52,,,365451.52,3106.94,365451.5184,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,633-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4536.77,,,4536.77,3106.94,8596.48447,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,633-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12895.44,,,12895.44,3106.94,28784.13961,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,633-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45767.68,,,45767.68,3106.94,70693.97307,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,633-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118356.06,,,118356.06,3106.94,165647.3831,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,634-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13470.34,,,13470.34,3106.94,16670.6012,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,634-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27630.58,,,27630.58,3106.94,30082.0623,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,634-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31200.01,,,31200.01,3106.94,46692.6104,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,634-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,90710.48,,,90710.48,3106.94,111116.6035,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,636-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12003.08,,,12003.08,3106.94,20470.7768,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,636-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22481.4,,,22481.4,3106.94,27780.88,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,636-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46475.06,,,46475.06,3106.94,53190.04349,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,636-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75095.48,,,75095.48,3106.94,95108.8903,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,639-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8393.66,,,8393.66,3106.94,14743.59053,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,639-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11480.66,,,11480.66,3106.94,27456.92353,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,639-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37596.48,,,37596.48,3106.94,45195.20027,case rate,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,639-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55518.62,,,55518.62,3106.94,79492.7076,case rate,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",640-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2652.08,,,2652.08,1692.285768,3626.0268,case rate,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",640-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3509.44,,,3509.44,2154.942842,5037.876,case rate,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",640-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6341.49,,,6341.49,3283.28,11197.3532,case rate,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",640-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47862.34,,,47862.34,3283.28,71164.92072,case rate,
SPLENIC PROCEDURES,650-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33414.65,,,33414.65,17516.64216,33414.6528,case rate,
SPLENIC PROCEDURES,650-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44220.42,,,44220.42,22954.71836,44220.4236,case rate,
SPLENIC PROCEDURES,650-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65164.57,,,65164.57,35121.11494,65164.572,case rate,
SPLENIC PROCEDURES,650-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106547.95,,,106547.95,55417.4107,118234.596,case rate,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,651-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25815.87,,,25815.87,10462.97736,25815.8688,case rate,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,651-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37791.45,,,37791.45,16851.10872,37791.4524,case rate,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,651-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51096.82,,,51096.82,32278.37174,54677.24657,case rate,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,651-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,117406.21,,,117406.21,78199.0308,158835.5423,case rate,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,660-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14750.14,,,14750.14,9472.099507,15356.49847,case rate,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,660-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17334.73,,,17334.73,10841.51496,18656.7268,case rate,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,660-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27023.18,,,27023.18,15981.46187,31547.8844,case rate,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,660-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58963.06,,,58963.06,45934.17773,103203.896,case rate,
COAGULATION AND PLATELET DISORDERS,661-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16994.78,,,16994.78,10362.77623,20931.0272,case rate,
COAGULATION AND PLATELET DISORDERS,661-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22633.88,,,22633.88,12003.10585,24584.0056,case rate,
COAGULATION AND PLATELET DISORDERS,661-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29240.32,,,29240.32,17730.65198,40547.6456,case rate,
COAGULATION AND PLATELET DISORDERS,661-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55698.59,,,55698.59,41091.12307,94664.3852,case rate,
SICKLE CELL ANEMIA CRISIS,662-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12165.55,,,12165.55,7726.620546,13865.5616,case rate,
SICKLE CELL ANEMIA CRISIS,662-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16682.33,,,16682.33,11199.0227,20010.5264,case rate,
SICKLE CELL ANEMIA CRISIS,662-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23653.71,,,23653.71,14193.92317,31941.7924,case rate,
SICKLE CELL ANEMIA CRISIS,662-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44472.88,,,44472.88,19756.94152,68670.6036,case rate,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,663-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11645.64,,,11645.64,5320.556351,11645.6364,case rate,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,663-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16472.36,,,16472.36,7001.70866,16472.364,case rate,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,663-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23003.82,,,23003.82,9911.252612,23020.8128,case rate,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,663-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38028.91,,,38028.91,20617.92902,48832.1528,case rate,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",680-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38263.88,,,38263.88,15089.5481,38263.8768,case rate,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",680-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50486.92,,,50486.92,20636.48478,50486.9208,case rate,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",680-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83031.71,,,83031.71,38646.71029,83031.7128,case rate,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",680-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,159069.54,,,159069.54,98899.75335,185474.6916,case rate,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",681-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28300.47,,,28300.47,11471.17392,28300.4712,case rate,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",681-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37141.56,,,37141.56,16049.49967,37141.5564,case rate,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",681-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63752.3,,,63752.3,29709.01682,79181.7276,case rate,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",681-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,135640.79,,,135640.79,68121.92447,185990.9184,case rate,
ACUTE LEUKEMIA,690-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20674.19,,,20674.19,20674.1916,32434.54717,case rate,
ACUTE LEUKEMIA,690-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40033.59,,,40033.59,31812.00352,56364.0884,case rate,
ACUTE LEUKEMIA,690-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74570.57,,,74570.57,57289.06886,125696.0428,case rate,
ACUTE LEUKEMIA,690-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,129836.72,,,129836.72,97509.30802,181469.2692,case rate,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",691-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21121.62,,,21121.62,11648.07222,23067.42111,case rate,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",691-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27375.62,,,27375.62,15364.17342,30766.288,case rate,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",691-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41008.44,,,41008.44,23463.14632,52093.2964,case rate,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",691-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76297.79,,,76297.79,43705.01183,131291.6096,case rate,
RADIOTHERAPY,692-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14820.13,,,14820.13,12354.1988,19865.42781,case rate,
RADIOTHERAPY,692-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25130.98,,,25130.98,15810.74883,34570.7116,case rate,
RADIOTHERAPY,692-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45587.7,,,45587.7,28178.78473,57713.7416,case rate,
RADIOTHERAPY,692-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81022.03,,,81022.03,47680.89374,94797.92966,case rate,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,694-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14902.62,,,14902.62,6308.9601,14902.6152,case rate,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,694-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18649.52,,,18649.52,8468.851146,20348.458,case rate,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,694-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27408.11,,,27408.11,13250.05326,33604.4988,case rate,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,694-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47344.92,,,47344.92,24004.97466,70103.1848,case rate,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,695-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13597.82,,,13597.82,9418.906314,18760.3868,case rate,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,695-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18834.49,,,18834.49,15518.8048,20201.17517,case rate,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,695-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39381.2,,,39381.2,31132.86252,54472.19281,case rate,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,695-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122195.45,,,122195.45,74918.28266,153143.1376,case rate,
OTHER CHEMOTHERAPY,696-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15784.97,,,15784.97,8993.36077,17082.55538,case rate,
OTHER CHEMOTHERAPY,696-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20101.78,,,20101.78,9808.577379,21769.49842,case rate,
OTHER CHEMOTHERAPY,696-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29925.21,,,29925.21,15220.6755,36767.71615,case rate,
OTHER CHEMOTHERAPY,696-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59480.48,,,59480.48,30712.26518,91104.7008,case rate,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,710-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24978.5,,,24978.5,8477.510503,24978.5028,case rate,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,710-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36136.72,,,36136.72,13063.25856,36136.7172,case rate,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,710-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59205.53,,,59205.53,22055.38228,61690.1392,case rate,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,710-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,109187.53,,,109187.53,54399.31773,131034.5328,case rate,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",711-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25383.44,,,25383.44,11346.23177,25383.438,case rate,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",711-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33192.19,,,33192.19,15597.97606,33192.1884,case rate,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",711-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54848.72,,,54848.72,27400.67965,59602.4268,case rate,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",711-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,102998.52,,,102998.52,59994.4994,125136.2788,case rate,
SEPTICEMIA AND DISSEMINATED INFECTIONS,720-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13955.27,,,13955.27,4986.552581,13955.2668,case rate,
SEPTICEMIA AND DISSEMINATED INFECTIONS,720-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17947.13,,,17947.13,6671.416043,17947.128,case rate,
SEPTICEMIA AND DISSEMINATED INFECTIONS,720-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26380.78,,,26380.78,10689.35769,30849.216,case rate,
SEPTICEMIA AND DISSEMINATED INFECTIONS,720-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46020.14,,,46020.14,22367.11913,66348.6196,case rate,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13525.34,,,13525.34,6469.77673,13525.3356,case rate,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17827.15,,,17827.15,8070.520724,17827.1472,case rate,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28113,,,28113,14030.63244,29679.9312,case rate,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50371.94,,,50371.94,27841.06981,58692.292,case rate,
FEVER AND INFLAMMATORY CONDITIONS,722-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9226.02,,,9226.02,4348.234265,10643.8088,case rate,
FEVER AND INFLAMMATORY CONDITIONS,722-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13842.78,,,13842.78,6099.898481,13842.7848,case rate,
FEVER AND INFLAMMATORY CONDITIONS,722-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18866.98,,,18866.98,8863.470415,18866.9808,case rate,
FEVER AND INFLAMMATORY CONDITIONS,722-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27383.12,,,27383.12,15852.80857,37151.744,case rate,
VIRAL ILLNESS,723-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8851.08,,,8851.08,4109.483422,9532.5736,case rate,
VIRAL ILLNESS,723-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12627.98,,,12627.98,6531.62928,12627.9792,case rate,
VIRAL ILLNESS,723-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18949.47,,,18949.47,9405.298753,19313.36,case rate,
VIRAL ILLNESS,723-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37431.51,,,37431.51,23387.68621,58763.36799,case rate,
OTHER INFECTIOUS AND PARASITIC DISEASES,724-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13605.32,,,13605.32,6918.826243,13605.3228,case rate,
OTHER INFECTIOUS AND PARASITIC DISEASES,724-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16299.89,,,16299.89,7115.517352,16299.8916,case rate,
OTHER INFECTIOUS AND PARASITIC DISEASES,724-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27195.65,,,27195.65,10074.54334,28255.6428,case rate,
OTHER INFECTIOUS AND PARASITIC DISEASES,724-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54796.23,,,54796.23,20912.34716,75062.2792,case rate,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,740-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,62735.032,per diem,BH/SA
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,740-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,62735.032,per diem,BH/SA
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,740-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,62735.032,per diem,BH/SA
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,740-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,102414.2121,per diem,BH/SA
SCHIZOPHRENIA,750-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,30820.1912,per diem,BH/SA
SCHIZOPHRENIA,750-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,35922.3364,per diem,BH/SA
SCHIZOPHRENIA,750-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,44998.806,per diem,BH/SA
SCHIZOPHRENIA,750-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,67191.66212,per diem,BH/SA
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,751-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,17790.1292,per diem,BH/SA
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,751-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,21897.1384,per diem,BH/SA
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,751-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,37218.0864,per diem,BH/SA
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,751-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,47849.456,per diem,BH/SA
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,752-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,19658.0824,per diem,BH/SA
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,752-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,19658.0824,per diem,BH/SA
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,752-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,39719.23351,per diem,BH/SA
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,752-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,62910.22861,per diem,BH/SA
BIPOLAR DISORDERS,753-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,17174.3888,per diem,BH/SA
BIPOLAR DISORDERS,753-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,21279.3248,per diem,BH/SA
BIPOLAR DISORDERS,753-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,34187.068,per diem,BH/SA
BIPOLAR DISORDERS,753-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,44570.94753,per diem,BH/SA
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,14365.2028,per diem,BH/SA
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,14365.2028,per diem,BH/SA
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,17667.8104,per diem,BH/SA
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,36008.34124,per diem,BH/SA
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10579.5396,per diem,BH/SA
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16724.5044,per diem,BH/SA
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,19860.85381,per diem,BH/SA
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,32470.60058,per diem,BH/SA
ACUTE ANXIETY AND DELIRIUM STATES,756-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10119.74096,per diem,BH/SA
ACUTE ANXIETY AND DELIRIUM STATES,756-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,12528.55928,per diem,BH/SA
ACUTE ANXIETY AND DELIRIUM STATES,756-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,18559.2864,per diem,BH/SA
ACUTE ANXIETY AND DELIRIUM STATES,756-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,34512.12481,per diem,BH/SA
ORGANIC MENTAL HEALTH DISTURBANCES,757-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16728.6508,per diem,BH/SA
ORGANIC MENTAL HEALTH DISTURBANCES,757-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,20286.39935,per diem,BH/SA
ORGANIC MENTAL HEALTH DISTURBANCES,757-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,26792.18882,per diem,BH/SA
ORGANIC MENTAL HEALTH DISTURBANCES,757-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,60416.49846,per diem,BH/SA
BEHAVIORAL DISORDERS,758-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,11153.816,per diem,BH/SA
BEHAVIORAL DISORDERS,758-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,23445.8188,per diem,BH/SA
BEHAVIORAL DISORDERS,758-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,23445.8188,per diem,BH/SA
BEHAVIORAL DISORDERS,758-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,30255.56933,per diem,BH/SA
EATING DISORDERS,759-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,26874.8916,per diem,BH/SA
EATING DISORDERS,759-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,27017.52262,per diem,BH/SA
EATING DISORDERS,759-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,43860.6192,per diem,BH/SA
EATING DISORDERS,759-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,81708.4556,per diem,BH/SA
OTHER MENTAL HEALTH DISORDERS,760-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,12464.52588,per diem,BH/SA
OTHER MENTAL HEALTH DISORDERS,760-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16861.3356,per diem,BH/SA
OTHER MENTAL HEALTH DISORDERS,760-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,28750.30229,per diem,BH/SA
OTHER MENTAL HEALTH DISORDERS,760-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,36459.00884,per diem,BH/SA
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,2690.585925,6198.868,per diem,BH/SA
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,3943.718588,7857.428,per diem,BH/SA
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16311.9376,per diem,BH/SA
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,43554.27021,per diem,BH/SA
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,772-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,20526.7532,per diem,BH/SA
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,772-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,20526.7532,per diem,BH/SA
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,772-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,20526.7532,per diem,BH/SA
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,772-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,50558.74824,per diem,BH/SA
OPIOID ABUSE AND DEPENDENCE,773-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,7596.2048,per diem,BH/SA
OPIOID ABUSE AND DEPENDENCE,773-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10334.902,per diem,BH/SA
OPIOID ABUSE AND DEPENDENCE,773-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,23483.1364,per diem,BH/SA
OPIOID ABUSE AND DEPENDENCE,773-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,41123.4185,per diem,BH/SA
COCAINE ABUSE AND DEPENDENCE,774-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,3928.873976,10274.7792,per diem,BH/SA
COCAINE ABUSE AND DEPENDENCE,774-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10378.4392,per diem,BH/SA
COCAINE ABUSE AND DEPENDENCE,774-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16765.9684,per diem,BH/SA
COCAINE ABUSE AND DEPENDENCE,774-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,45820.27499,per diem,BH/SA
ALCOHOL ABUSE AND DEPENDENCE,775-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,9460.0116,per diem,BH/SA
ALCOHOL ABUSE AND DEPENDENCE,775-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,13477.8732,per diem,BH/SA
ALCOHOL ABUSE AND DEPENDENCE,775-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,25550.1168,per diem,BH/SA
ALCOHOL ABUSE AND DEPENDENCE,775-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,81254.9276,per diem,BH/SA
OTHER DRUG ABUSE AND DEPENDENCE,776-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10842.836,per diem,BH/SA
OTHER DRUG ABUSE AND DEPENDENCE,776-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,11475.162,per diem,BH/SA
OTHER DRUG ABUSE AND DEPENDENCE,776-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,18763.54553,per diem,BH/SA
OTHER DRUG ABUSE AND DEPENDENCE,776-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,34820.09947,per diem,BH/SA
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,792-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33467.14,,,33467.14,15069.75528,33467.1444,case rate,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,792-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42333.23,,,42333.23,20370.51882,42333.2256,case rate,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,792-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63072.41,,,63072.41,33589.6458,63072.4068,case rate,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,792-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118398.55,,,118398.55,68771.37624,118398.5532,case rate,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,793-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24308.61,,,24308.61,10675.75013,24308.61,case rate,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,793-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32242.34,,,32242.34,15087.074,32242.3404,case rate,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,793-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47779.85,,,47779.85,23333.25596,47779.854,case rate,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,793-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93227.58,,,93227.58,46405.49416,93227.5812,case rate,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,794-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20769.18,,,20769.18,9081.191391,20769.1764,case rate,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,794-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26695.73,,,26695.73,10116.60308,26695.728,case rate,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,794-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38841.28,,,38841.28,18643.59562,38841.2844,case rate,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,794-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,69516.38,,,69516.38,44248.07722,69516.3756,case rate,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,810-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11050.73,,,11050.73,5887.125709,11239.64994,case rate,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,810-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15420.03,,,15420.03,8214.01864,15420.0324,case rate,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,810-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24233.62,,,24233.62,12911.10129,24793.47801,case rate,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,810-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49864.52,,,49864.52,26564.43317,49864.5204,case rate,
ALLERGIC REACTIONS,811-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7813.75,,,7813.75,3623.322379,7813.7496,case rate,
ALLERGIC REACTIONS,811-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11623.14,,,11623.14,5976.193381,11623.14,case rate,
ALLERGIC REACTIONS,811-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22351.42,,,22351.42,10055.98758,22351.4232,case rate,
ALLERGIC REACTIONS,811-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43675.51,,,43675.51,22568.75844,49700.37206,case rate,
POISONING OF MEDICINAL AGENTS,812-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8626.12,,,8626.12,4079.794198,8626.1196,case rate,
POISONING OF MEDICINAL AGENTS,812-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12308.03,,,12308.03,5519.721562,12308.0304,case rate,
POISONING OF MEDICINAL AGENTS,812-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18032.11,,,18032.11,7542.299947,19073.44,case rate,
POISONING OF MEDICINAL AGENTS,812-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32077.37,,,32077.37,16447.8301,45328.4448,case rate,
OTHER COMPLICATIONS OF TREATMENT,813-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13412.85,,,13412.85,5669.404733,13412.8536,case rate,
OTHER COMPLICATIONS OF TREATMENT,813-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16522.36,,,16522.36,7962.897287,16522.356,case rate,
OTHER COMPLICATIONS OF TREATMENT,813-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23961.17,,,23961.17,12449.68126,23961.1656,case rate,
OTHER COMPLICATIONS OF TREATMENT,813-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42948.13,,,42948.13,22671.43368,54185.1552,case rate,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",815-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9378.5,,,9378.5,4531.317813,9506.833022,case rate,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",815-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13352.86,,,13352.86,6949.752518,13352.8632,case rate,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",815-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21879,,,21879,11911.56408,22497.32659,case rate,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",815-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45947.65,,,45947.65,21705.29685,60952.7929,case rate,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12685.47,,,12685.47,4087.216504,12685.47,case rate,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13430.35,,,13430.35,5840.117771,13430.3508,case rate,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17749.66,,,17749.66,7023.975578,18266.9652,case rate,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32034.87,,,32034.87,15849.09741,43412.808,case rate,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,817-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9386,,,9386,7189.740412,9385.998,case rate,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,817-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11833.11,,,11833.11,9691.057534,11833.1064,case rate,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,817-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19226.92,,,19226.92,13397.26233,19226.9232,case rate,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,817-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34904.41,,,34904.41,22312.68889,34904.4144,case rate,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,841-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38711.31,,,38711.31,26814.31748,111264.4976,case rate,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,841-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44065.45,,,44065.45,30521.75932,146821.9508,case rate,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,841-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,150520.91,,,150520.91,109203.1511,303576.6028,case rate,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,841-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,410151.87,,,410151.87,225396.8775,410151.8652,case rate,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,842-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29215.32,,,29215.32,19083.98578,44681.6064,case rate,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,842-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45315.25,,,45315.25,24716.27898,58762.7808,case rate,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,842-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85481.32,,,85481.32,42663.41489,93889.83445,case rate,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,842-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,207279.33,,,207279.33,123239.9688,216388.0481,case rate,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,843-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11253.2,,,11253.2,6250.818703,40871.0648,case rate,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,843-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17269.74,,,17269.74,7184.792208,40871.0648,case rate,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,843-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23401.26,,,23401.26,11055.52479,40871.0648,case rate,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,843-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48189.79,,,48189.79,27429.13182,92760.91211,case rate,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,844-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8851.08,,,8851.08,3558.995727,13461.2876,case rate,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,844-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14342.7,,,14342.7,7095.724536,22050.5552,case rate,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,844-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24651.06,,,24651.06,13734.97725,39019.6972,case rate,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,844-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56925.89,,,56925.89,37509.86042,119309.2333,case rate,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",850-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40893.46,,,40893.46,16233.82027,40893.456,case rate,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",850-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55463.62,,,55463.62,26437.01692,55463.6244,case rate,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",850-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,67991.62,,,67991.62,33009.46888,67991.6196,case rate,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",850-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144451.88,,,144451.88,65129.4981,158116.7444,case rate,
REHABILITATION,860-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23808.69,,,23808.69,14210.00484,31767.6436,case rate,
REHABILITATION,860-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29185.33,,,29185.33,17966.92872,37191.1348,case rate,
REHABILITATION,860-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37171.55,,,37171.55,20564.73582,49180.4504,case rate,
REHABILITATION,860-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45535.21,,,45535.21,22327.5335,49180.4504,case rate,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",861-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8468.64,,,8468.64,5162.213823,10782.22233,case rate,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",861-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14677.65,,,14677.65,6654.097329,14677.6512,case rate,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",861-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20534.21,,,20534.21,10072.06924,21930.3096,case rate,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",861-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22178.95,,,22178.95,20888.84319,43334.0264,case rate,
OTHER AFTERCARE AND CONVALESCENCE,862-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11475.66,,,11475.66,4630.281893,12895.85337,case rate,
OTHER AFTERCARE AND CONVALESCENCE,862-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16722.32,,,16722.32,6746.876154,17745.03675,case rate,
OTHER AFTERCARE AND CONVALESCENCE,862-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18684.51,,,18684.51,7539.825845,26528.54827,case rate,
OTHER AFTERCARE AND CONVALESCENCE,862-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19619.36,,,19619.36,7915.889349,44418.31,case rate,
NEONATAL AFTERCARE,863-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21059.13,,,21059.13,12751.52171,21059.13,case rate,
NEONATAL AFTERCARE,863-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53571.43,,,53571.43,18800.7011,53571.4272,case rate,
NEONATAL AFTERCARE,863-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,104410.79,,,104410.79,43645.63338,104410.7916,case rate,
NEONATAL AFTERCARE,863-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,162726.46,,,162726.46,109858.868,225297.7466,case rate,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,890-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19994.3,,,19994.3,10628.74219,23085.082,case rate,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,890-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21046.63,,,21046.63,11189.1263,25146.31929,case rate,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,890-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31397.48,,,31397.48,16691.52914,39929.832,case rate,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,890-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59995.4,,,59995.4,31893.64888,80427.67131,case rate,
HIV WITH MAJOR HIV RELATED CONDITION,892-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16769.82,,,16769.82,8930.271169,16769.8164,case rate,
HIV WITH MAJOR HIV RELATED CONDITION,892-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17814.65,,,17814.65,9432.513875,19345.0292,case rate,
HIV WITH MAJOR HIV RELATED CONDITION,892-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24681.05,,,24681.05,12723.06954,27148.554,case rate,
HIV WITH MAJOR HIV RELATED CONDITION,892-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38388.86,,,38388.86,24712.56783,48398.854,case rate,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18472.04,,,18472.04,10636.1645,18472.044,case rate,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20009.3,,,20009.3,11138.4072,20009.298,case rate,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27928.03,,,27928.03,13720.13264,30111.1568,case rate,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42635.68,,,42635.68,28810.91779,50292.65865,case rate,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,894-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13617.82,,,13617.82,6723.372185,13617.8208,case rate,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,894-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17042.27,,,17042.27,8786.773253,17042.2728,case rate,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,894-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24656.05,,,24656.05,13374.99541,24656.0544,case rate,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,894-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38108.9,,,38108.9,24032.5344,41338.26131,case rate,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74363.1,,,74363.1,41677.48524,77939.8808,case rate,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85066.39,,,85066.39,47677.18259,85066.3872,case rate,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95769.67,,,95769.67,53675.64289,95769.6744,case rate,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,160729.28,,,160729.28,90084.52792,189232.1738,case rate,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,911-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38723.8,,,38723.8,26156.06741,40947.65814,case rate,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,911-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52459.11,,,52459.11,30735.76915,52459.1052,case rate,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,911-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71461.06,,,71461.06,31043.79485,71461.0644,case rate,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,911-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,151848.2,,,151848.2,67139.70597,158230.479,case rate,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51666.73,,,51666.73,27601.08191,51666.732,case rate,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52399.11,,,52399.11,27690.14958,52399.1148,case rate,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83091.7,,,83091.7,31402.53964,83091.7032,case rate,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,147533.89,,,147533.89,62592.3065,157078.0712,case rate,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,930-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18694.51,,,18694.51,8180.618263,18694.5084,case rate,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,930-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22506.4,,,22506.4,9733.117268,22506.3984,case rate,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,930-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35419.33,,,35419.33,14993.05812,35419.332,case rate,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,930-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,68199.09,,,68199.09,30959.67538,88840.39988,case rate,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35254.36,,,35254.36,14584.83129,35254.3584,case rate,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47919.83,,,47919.83,20831.93884,47919.8316,case rate,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72555.89,,,72555.89,33165.33731,82811.9008,case rate,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,132376.32,,,132376.32,71562.1633,168225.6676,case rate,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26835.71,,,26835.71,11862.08204,26835.7056,case rate,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36514.16,,,36514.16,15976.51367,36514.1568,case rate,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54886.22,,,54886.22,26771.02069,56221.0376,case rate,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98389.26,,,98389.26,52603.11967,130095.3732,case rate,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21918.99,,,21918.99,9786.310461,21918.9924,case rate,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30187.67,,,30187.67,13476.43359,30187.6692,case rate,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48092.3,,,48092.3,25246.97386,50666.9348,case rate,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84591.46,,,84591.46,49125.76931,122973.9312,case rate,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.7355,1592,other,SI=N Exclusions 
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,399.86,2141,fee schedule,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,57.921,1592,other,SI=N Exclusions 
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,195.5395,1592,fee schedule,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,155.354,2141,fee schedule,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,291.227805,2141,fee schedule,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,29.185,1592,other,SI=N Exclusions 
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,761,RC,,,outpatient,,,922,645.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,206.989,1592,fee schedule,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,761,RC,,,outpatient,,,922,645.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,206.989,1592,fee schedule,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,761,RC,,,outpatient,,,4838,3386.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3715.584,fee schedule,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,205.642,1592,fee schedule,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,761,RC,,,outpatient,,,916,641.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,205.642,1592,fee schedule,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,761,RC,,,outpatient,,,8640,6048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6635.52,fee schedule,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,263.563,1592,fee schedule,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.8985,1592,other,SI=N Exclusions 
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1159.73,,,1159.73,399.86,2998,fee schedule,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1573.05,,,1573.05,399.86,2998,fee schedule,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1538.39,399.86,2998,percent of total billed charges,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,553.04,,,553.04,158.497,3914,fee schedule,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,399.86,2141,fee schedule,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,399.86,2141,fee schedule,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,761,RC,,,outpatient,,,1018,712.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,228.541,1592,fee schedule,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,761,RC,,,outpatient,,,1065,745.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,239.0925,1592,fee schedule,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,761,RC,,,outpatient,,,2829,1980.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,761,RC,,,outpatient,,,1203,842.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.0735,1592,other,SI=N Exclusions 
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,761,RC,,,outpatient,,,1203,842.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.0735,1592,other,SI=N Exclusions 
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,761,RC,,,outpatient,,,1910,1337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1592,other,SI=N Exclusions 
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,761,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,62.19,1592,fee schedule,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,761,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,66.75974,1592,fee schedule,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,47.594,1592,fee schedule,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,761,RC,,,outpatient,,,431,301.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,96.7595,1592,fee schedule,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.2055,1592,other,SI=N Exclusions 
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,35.6955,1592,fee schedule,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,761,RC,,,outpatient,,,1914,1339.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,399.86,1592,fee schedule,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,399.86,2141,fee schedule,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,113.876282,1592,fee schedule,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,156.65,1592,fee schedule,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,761,RC,,,outpatient,,,505,353.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,113.3725,1592,fee schedule,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,761,RC,,,outpatient,,,505,353.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,113.3725,1592,fee schedule,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,761,RC,,,outpatient,,,445,311.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,99.9025,1592,fee schedule,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,115.1685,1592,fee schedule,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,145.476,1592,fee schedule,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,95.4125,1592,fee schedule,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,73.8605,1592,fee schedule,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,89.8,1592,fee schedule,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,107.5355,1592,fee schedule,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,142.1085,1592,fee schedule,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,174.8855,1592,fee schedule,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,124.5975,1592,fee schedule,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,100.576,1592,fee schedule,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,309.1365,1592,fee schedule,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,181.6205,1592,fee schedule,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,200.0295,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,113.3725,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,153.7825,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,153.7825,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,145.7005,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,3459.072,fee schedule,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,142.333,1592,fee schedule,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,142.1085,1592,fee schedule,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,139.8635,1592,fee schedule,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,140.7615,1592,fee schedule,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,237.072,2141,fee schedule,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,4022.784,fee schedule,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,200.0295,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,133.802,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,148.8435,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,146.374,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,168.1505,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,318.5655,1592,fee schedule,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,254.134,1592,fee schedule,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,399.86,1592,fee schedule,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,244.705,1592,fee schedule,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,56.125,1592,other,SI=N Exclusions 
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,395.3445,1592,fee schedule,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,165.0075,1592,fee schedule,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.4725,1592,other,SI=N Exclusions 
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,257.0525,1592,fee schedule,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,162.3135,1592,fee schedule,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.761,1592,other,SI=N Exclusions 
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,395.3445,1592,fee schedule,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,166.8035,1592,fee schedule,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,103.719,1592,other,SI=N Exclusions 
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,3459.072,fee schedule,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,108.7,1592,fee schedule,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,4341.777195,fee schedule,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,5804.544,fee schedule,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3770.57,,,3770.57,399.86,7323.648,fee schedule,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,4478.208,fee schedule,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,5804.544,fee schedule,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3770.57,,,3770.57,399.86,5481.863562,fee schedule,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,7323.648,fee schedule,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,5804.544,fee schedule,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,88.2285,1592,fee schedule,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,761,RC,,,outpatient,,,812,568.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,182.294,1592,fee schedule,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,761,RC,,,outpatient,,,812,568.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,182.294,1592,fee schedule,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,761,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,189.7025,1592,fee schedule,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,567.89,150.415,2998,percent of total billed charges,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,395.7935,1592,fee schedule,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,367.5065,2141,fee schedule,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.47,1592,other,SI=N Exclusions 
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3315.456,fee schedule,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3070.464,other,SI=N Exclusions 
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1794.048,other,SI=N Exclusions 
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3932.16,fee schedule,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1714.176,other,SI=N Exclusions 
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,108.7,2998,fee schedule,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,197.56,1592,other,SI=N Exclusions 
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,108.7,2141,fee schedule,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.858,1592,other,SI=N Exclusions 
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,108.7,2141,fee schedule,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,61.513,1592,other,SI=N Exclusions 
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,108.7,2141,fee schedule,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11904.54,399.86,14403.82399,percent of total billed charges,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,761,RC,,,outpatient,,,3847,2692.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2954.496,fee schedule,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions 
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4007.424,fee schedule,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,4449.024,fee schedule,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,184.7635,1592,fee schedule,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,202.7235,1592,fee schedule,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,147.721,1592,fee schedule,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,160.293,1592,fee schedule,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,160.293,1592,fee schedule,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,210.581,1592,fee schedule,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,169.0485,1592,fee schedule,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,169.0485,1592,fee schedule,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,399.86,2141,fee schedule,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,147.721,1592,fee schedule,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,147.721,1592,fee schedule,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,176.008,1592,fee schedule,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7769.23,,,7769.23,399.86,20110.10933,fee schedule,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3683.328,fee schedule,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,380.5275,1592,other,SI=N Exclusions 
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions 
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,306.82,,,306.82,165.0075,1592,fee schedule,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,2998,fee schedule,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4341.777195,fee schedule,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4007.424,fee schedule,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,274.788,1592,other,SI=N Exclusions 
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,3826.944,fee schedule,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7769.23,,,7769.23,399.86,16604.928,fee schedule,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4007.424,fee schedule,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions 
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,2455.793921,fee schedule,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,3826.944,fee schedule,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,3826.944,fee schedule,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,3826.944,fee schedule,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2841.6,fee schedule,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2841.6,fee schedule,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions 
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1512.98,,,1512.98,399.86,2998,fee schedule,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,306.82,,,306.82,202.499,1592,fee schedule,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,2455.793921,fee schedule,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,306.82,,,306.82,150.6395,1592,fee schedule,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,2998,fee schedule,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,160.5175,1592,other,Unlisted Codes
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,5885.184,fee schedule,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,324.627,1592,other,SI=N Exclusions 
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,187.233,1592,other,SI=N Exclusions 
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,292.65,2813.184,fee schedule,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,321.12,,,321.12,149.068,1592,fee schedule,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,321.12,,,321.12,200.4785,1592,fee schedule,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,110.2295,1592,fee schedule,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,114.7195,1592,fee schedule,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,101.6985,1592,fee schedule,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,79.473,1592,fee schedule,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,79.473,1592,fee schedule,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,49.6145,1592,fee schedule,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,48.941,1592,fee schedule,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,90.9225,1592,fee schedule,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,27.389,1592,fee schedule,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,27.389,1592,fee schedule,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,321.12,,,321.12,156.9255,1592,fee schedule,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,124.373,1592,fee schedule,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,79.473,1592,fee schedule,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,77.9015,1592,fee schedule,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,77.9015,1592,fee schedule,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,64.8805,1592,fee schedule,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,64.8805,1592,fee schedule,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,109.107,1592,fee schedule,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,114.495,1592,fee schedule,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,122.128,1592,fee schedule,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,122.128,1592,fee schedule,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,122.128,1592,fee schedule,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,138.0675,1592,fee schedule,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,223.51,,,223.51,83.2895,1592,fee schedule,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1866.51,,,1866.51,399.86,2998,fee schedule,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1866.51,,,1866.51,399.86,2998,fee schedule,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1866.51,,,1866.51,399.86,3022.08,fee schedule,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1866.51,,,1866.51,399.86,2998,fee schedule,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1906.39,,,1906.39,399.86,3528.192,fee schedule,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6425.856,fee schedule,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,2141,fee schedule,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1624.73,,,1624.73,399.86,3224.064,fee schedule,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,2141,fee schedule,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,367.282,2141,fee schedule,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,367.282,2141,fee schedule,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2021.99,,,2021.99,399.86,2998,fee schedule,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,1739.52,fee schedule,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,319.0145,2141,fee schedule,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,319.0145,2141,fee schedule,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2130.85,,,2130.85,399.86,4252.416,fee schedule,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2130.85,,,2130.85,399.86,4252.416,fee schedule,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,28237.056,fee schedule,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,16478.208,fee schedule,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,16478.208,fee schedule,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,4870.452937,fee schedule,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,16478.208,fee schedule,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24098.62,,,24098.62,399.86,37615.872,fee schedule,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,3459.072,fee schedule,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,2998,fee schedule,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6364,other,SI=N Exclusions 
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,4870.452937,fee schedule,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,13659.648,fee schedule,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,16316.30039,fee schedule,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24098.62,,,24098.62,399.86,29773.2518,fee schedule,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29983.82,,,29983.82,399.86,51836.928,fee schedule,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41788.33,,,41788.33,399.86,50269.54813,fee schedule,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,16478.208,fee schedule,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6933.504,fee schedule,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41788.33,,,41788.33,399.86,66342.912,fee schedule,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29983.82,,,29983.82,399.86,48388.608,fee schedule,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29983.82,,,29983.82,399.86,50497.536,fee schedule,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41788.33,,,41788.33,399.86,50497.536,fee schedule,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2738.42,,,2738.42,399.86,21295.104,fee schedule,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24913.51,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3094.93,,,3094.93,399.86,21295.104,fee schedule,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3192.45,,,3192.45,399.86,22573.824,fee schedule,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3593.11,,,3593.11,399.86,22573.824,fee schedule,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24913.51,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,23502.25,399.86,23502.2528,percent of total billed charges,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24913.51,399.86,24913.5068,percent of total billed charges,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24913.51,399.86,24913.5068,percent of total billed charges,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3592.89,,,3592.89,399.86,5338.368,fee schedule,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3084.78,,,3084.78,399.86,4584.96,fee schedule,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3746.39,399.86,3746.392,percent of total billed charges,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1397.69,370.2005,2998,percent of total billed charges,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3237.83,399.86,3237.832,percent of total billed charges,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1897.1,,,1897.1,399.86,3220.992,fee schedule,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1525.68,399.86,2998,percent of total billed charges,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,524.25,,,524.25,399.86,6913,fee schedule,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,117.82,31.2055,6913,percent of total billed charges,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,860.21,,,860.21,399.86,3155.712,fee schedule,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3549.75,399.86,3549.7488,percent of total billed charges,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3549.75,399.86,3549.7488,percent of total billed charges,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,660.2,,,660.2,399.86,3155.712,fee schedule,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,293.59,,,293.59,293.5896,3216.384,fee schedule,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,397.365,2141,other,Unlisted Codes
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,397.365,2141,other,Unlisted Codes
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,420.73,,,420.73,34.124,2998,fee schedule,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,412.75,,,412.75,53.431,2998,fee schedule,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,141.55,37.4915,2998,percent of total billed charges,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,285.64,75.6565,2998,percent of total billed charges,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,378.88,100.3515,2998,percent of total billed charges,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,184.78,48.941,2998,percent of total billed charges,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,77.0035,1592,other,SI=N Exclusions 
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,173.9875,2141,fee schedule,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,57.921,1592,other,SI=N Exclusions 
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,121.4545,1592,other,SI=N Exclusions 
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,173.5385,1592,other,SI=N Exclusions 
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,204.0705,1592,other,SI=N Exclusions 
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6398.208,other,SI=N Exclusions 
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,161.8645,1592,other,SI=N Exclusions 
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,373.119,1592,other,SI=N Exclusions 
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,140.986,1592,other,SI=N Exclusions 
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,76.33,1592,other,SI=N Exclusions 
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2003.712,other,SI=N Exclusions 
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,161.8645,1592,other,SI=N Exclusions 
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.235,1592,other,SI=N Exclusions 
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.516,1592,other,SI=N Exclusions 
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,346.8525,1592,other,SI=N Exclusions 
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.4705,1592,other,SI=N Exclusions 
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7442.688,fee schedule,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7442.688,fee schedule,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,8396.844904,fee schedule,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,12170.496,fee schedule,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7020.288,fee schedule,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,12170.496,fee schedule,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,115.6175,1592,other,SI=N Exclusions 
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.394,1592,other,SI=N Exclusions 
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.5215,1592,other,SI=N Exclusions 
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,277.482,1592,other,SI=N Exclusions 
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,323.729,1592,other,SI=N Exclusions 
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,57.921,1592,other,SI=N Exclusions 
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7242.24,fee schedule,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7242.24,fee schedule,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,8396.844904,fee schedule,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7242.24,fee schedule,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.388,416.02,other,SI=N Exclusions 
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,521.94,,,521.94,207.2135,1592,fee schedule,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,156.65,1592,fee schedule,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,204.0705,1592,fee schedule,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,85.9835,1592,fee schedule,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,6623.08,fee schedule,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1592,other,SI=N Exclusions 
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1592,other,SI=N Exclusions 
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,205.4175,1592,other,SI=N Exclusions 
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,92.494,1592,other,SI=N Exclusions 
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,173.5385,1592,other,SI=N Exclusions 
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,521.94,,,521.94,300.1565,2081.64,fee schedule,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1699.82,,,1699.82,399.86,3777.792,fee schedule,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,5781.504,fee schedule,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,5781.504,fee schedule,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,6012.672,fee schedule,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,6012.672,fee schedule,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,6012.672,fee schedule,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,2840.064,fee schedule,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2953.728,fee schedule,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2953.728,fee schedule,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,319.0145,2141,fee schedule,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,319.0145,2141,fee schedule,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,2998,fee schedule,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,35.92,1592,fee schedule,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,28.0625,1592,fee schedule,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,180.947,1592,fee schedule,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,91.147,1592,fee schedule,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,66.6765,1592,fee schedule,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,69.3705,1592,other,SI=N Exclusions 
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,9071.02,399.86,9071.0152,percent of total billed charges,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,474.58,,,474.58,127.516,1592,fee schedule,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,474.58,,,474.58,127.516,1592,fee schedule,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1648.58,,,1648.58,399.86,5756,fee schedule,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,18955.84,fee schedule,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,26793.51305,fee schedule,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,184.988,4800.911611,other,SI=N Exclusions 
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,277.482,8164.18419,other,SI=N Exclusions 
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,20286.72,fee schedule,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,6788.57,fee schedule,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,10775.04,fee schedule,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7394.304,fee schedule,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7678.464,fee schedule,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,137.6185,1592,fee schedule,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,6777.6,fee schedule,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,4870.452937,fee schedule,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,5548.032,fee schedule,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,5548.032,fee schedule,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2034.53,,,2034.53,124.1485,2998,fee schedule,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,12283.392,fee schedule,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,18955.84,fee schedule,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12148.224,other,SI=N Exclusions 
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12453.888,other,SI=N Exclusions 
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,12748.032,fee schedule,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,26793.51305,fee schedule,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,25020.672,fee schedule,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,45315.84,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,16809.6787,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,44656.128,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12327.936,other,SI=N Exclusions 
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,25786.368,other,SI=N Exclusions 
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12327.936,other,SI=N Exclusions 
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12148.224,other,SI=N Exclusions 
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4532,other,SI=N Exclusions 
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4532,other,SI=N Exclusions 
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,26793.51305,fee schedule,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3565.824,fee schedule,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,85.5345,1592,other,SI=N Exclusions 
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4341.777195,fee schedule,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4341.777195,fee schedule,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.25,1592,other,SI=N Exclusions 
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,481.85,,,481.85,121.23,1592,fee schedule,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,367.5065,2141,fee schedule,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,95.188,1592,other,SI=N Exclusions 
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,664.02,,,664.02,119.6585,1592,fee schedule,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,153.7825,1592,fee schedule,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,474.58,,,474.58,72.9625,1592,fee schedule,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,474.58,,,474.58,72.9625,1592,fee schedule,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,129.9855,1592,fee schedule,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,111.352,1592,fee schedule,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,197.3355,1592,fee schedule,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,197.3355,1592,fee schedule,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,375.5885,2998,fee schedule,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1335.58,,,1335.58,399.86,4005.9,fee schedule,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3182.32,,,3182.32,399.86,4934.4,fee schedule,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1335.58,,,1335.58,399.86,2998,fee schedule,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,218.214,1592,other,SI=N Exclusions 
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6264.7,,,6264.7,399.86,10219.776,fee schedule,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6425.856,fee schedule,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6425.856,fee schedule,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6264.7,,,6264.7,399.86,15728.70471,fee schedule,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2213.02,,,2213.02,390.63,2998,fee schedule,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1567.5,,,1567.5,399.86,6577.152,fee schedule,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2124.05,,,2124.05,399.86,6577.152,fee schedule,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,207.6625,2998,fee schedule,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,367.0575,2998,fee schedule,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,367.0575,2998,fee schedule,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6425.856,fee schedule,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6116.352,fee schedule,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2021.99,,,2021.99,399.86,3280.128,fee schedule,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,110.2295,1592,other,SI=N Exclusions 
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2021.99,,,2021.99,399.86,3280.128,fee schedule,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2021.99,,,2021.99,399.86,3280.128,fee schedule,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,369.078,2998,fee schedule,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,369.078,2998,fee schedule,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,379.854,2998,fee schedule,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,379.854,2998,fee schedule,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,2998,fee schedule,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,2998,fee schedule,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,2998,fee schedule,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,136.047,1592,fee schedule,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.38,1.160665,416.02,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,42.63,1.160665,416.02,percent of total billed charges,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,4179.83,fee schedule,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,766.41,,,766.41,339.6685,2141,fee schedule,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,162.987,2141,fee schedule,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,119.6585,1592,fee schedule,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,766.41,,,766.41,334.48,2141,fee schedule,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,4225.536,fee schedule,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5480.48,,,5480.48,399.86,8911.104,fee schedule,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6264.7,,,6264.7,399.86,10219.776,fee schedule,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,83.963,1592,other,SI=N Exclusions 
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,119.6585,1592,other,SI=N Exclusions 
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5480.48,,,5480.48,399.86,8911.104,fee schedule,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5480.48,,,5480.48,399.86,8911.104,fee schedule,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,156.9255,1592,fee schedule,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,156.9255,1592,fee schedule,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1244.25,,,1244.25,179.53,2998,fee schedule,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1244.25,,,1244.25,179.53,2998,fee schedule,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions 
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,219.112,1592,other,SI=N Exclusions 
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,197.3355,1592,fee schedule,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,87.3305,1592,fee schedule,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,87.7795,1592,fee schedule,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,79.473,1592,fee schedule,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,102.372,1592,fee schedule,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,106.6375,1592,fee schedule,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,47.594,1592,fee schedule,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3989.66,,,3989.66,399.86,6210.048,fee schedule,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,5068.032,fee schedule,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,120.28264,1592,fee schedule,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,372.13,,,372.13,186.1105,1592,fee schedule,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3218.7,,,3218.7,399.86,4777.053449,fee schedule,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions 
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3218.7,,,3218.7,399.86,5299.2,fee schedule,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,226.18,,,226.18,110.005,416.02,fee schedule,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3218.7,,,3218.7,399.86,4777.053449,fee schedule,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3218.7,,,3218.7,399.86,5511.168,fee schedule,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,339.893,2141,fee schedule,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11413.04,other,Unlisted Codes
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,399.86,2141,fee schedule,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2346.02,,,2346.02,119.6585,5756,fee schedule,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,367.5065,2141,fee schedule,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,205.4175,2141,fee schedule,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,205.4175,2141,fee schedule,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,205.4175,2141,fee schedule,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,281.972,2141,fee schedule,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,281.972,2141,fee schedule,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,205.4175,2141,fee schedule,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,294.544,1592,other,SI=N Exclusions 
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6224.09,,,6224.09,399.86,6224.0876,fee schedule,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,281.972,1592,other,SI=N Exclusions 
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.5215,1592,other,SI=N Exclusions 
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,399.86,2141,fee schedule,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,382.23,,,382.23,155.844464,1592,fee schedule,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,200.0295,1592,fee schedule,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,323.2601,1592,fee schedule,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,196.8865,1592,fee schedule,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,346.628,2141,fee schedule,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,346.628,2141,fee schedule,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,346.628,2141,fee schedule,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,310.259,2141,fee schedule,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,346.628,2141,fee schedule,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,346.628,2141,fee schedule,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,399.86,2141,fee schedule,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,346.628,2141,fee schedule,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,4677.12,fee schedule,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,366.833,2141,fee schedule,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,185.2125,1592,fee schedule,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.635,1592,other,SI=N Exclusions 
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,93.392,1592,other,SI=N Exclusions 
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,49.6145,1592,other,SI=N Exclusions 
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,50.288,1592,other,SI=N Exclusions 
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,380.0785,1592,other,SI=N Exclusions 
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.123,1592,other,SI=N Exclusions 
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,154.2315,1592,other,Unlisted Codes
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,154.2315,1592,other,Unlisted Codes
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,761,RC,,,outpatient,,,205,143.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,46.0225,1592,fee schedule,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,761,RC,,,outpatient,,,305,213.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,66.75974,1592,fee schedule,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,60.8395,416.02,fee schedule,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,456.96,fee schedule,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.208,416.02,fee schedule,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,66.2275,416.02,fee schedule,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,56.574,416.02,fee schedule,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,73.636,416.02,fee schedule,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,58.819,416.02,fee schedule,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,549.888,fee schedule,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,267.439885,1987.584,fee schedule,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.084,416.02,fee schedule,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,58.819,416.02,fee schedule,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,120.5565,646.6965,fee schedule,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,89.81,821.76,fee schedule,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,124.33,1023.744,fee schedule,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,153.75,1240.32,fee schedule,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,575,fee schedule,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,173.763,667.43,fee schedule,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1243.392,fee schedule,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,921.6,fee schedule,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1014.528,fee schedule,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,889.344,fee schedule,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,575,fee schedule,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,194.55,1138.176,fee schedule,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1347.84,fee schedule,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1021.44,fee schedule,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,888.576,fee schedule,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,3902.208,fee schedule,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,365.99,2081.28,fee schedule,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,379.854,1299.456,fee schedule,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,267.439885,1750.272,fee schedule,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,374.62,1750.272,fee schedule,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,301.425681,1750.272,fee schedule,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,267.439885,1675.776,fee schedule,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.86,1896.192,fee schedule,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,301.425681,1946.112,fee schedule,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,188.66,1605.12,fee schedule,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,268.7,4035.84,fee schedule,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,307.14,2049.024,fee schedule,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,48.043,416.02,fee schedule,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.084,416.02,fee schedule,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,55.0025,416.02,fee schedule,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,431.616,fee schedule,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,56.125,416.02,fee schedule,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,1065.984,fee schedule,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,195.34,1247.232,fee schedule,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1522.176,fee schedule,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,217.12,,,217.12,59.268,575,fee schedule,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1222.656,fee schedule,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,1519.872,fee schedule,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1867.69,,,1867.69,399.86,2402.304,fee schedule,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,347.3015,1288.93,fee schedule,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1286.6,,,1286.6,301.425681,1817.856,fee schedule,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1286.6,,,1286.6,301.425681,1817.856,fee schedule,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1286.6,,,1286.6,301.425681,1817.856,fee schedule,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,56.3495,416.02,fee schedule,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,66.452,416.02,fee schedule,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,67.35,416.02,fee schedule,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,67.35,416.02,fee schedule,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,56.574,416.02,fee schedule,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,63.5335,416.02,fee schedule,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,68.697,416.02,fee schedule,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.4325,416.02,fee schedule,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,581.376,fee schedule,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,581.376,fee schedule,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,52.7575,416.02,fee schedule,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,72.5135,416.02,fee schedule,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,462.336,fee schedule,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,92.2695,416.02,fee schedule,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,1043.712,fee schedule,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,196.52,1195.008,fee schedule,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1719.552,fee schedule,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,698.112,fee schedule,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,196.52,796.416,fee schedule,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1704.192,fee schedule,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,575,fee schedule,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,195.73,1095.936,fee schedule,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1057.536,fee schedule,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,185.92,1624.32,fee schedule,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,270.27,2337.024,fee schedule,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,185.92,1706.496,fee schedule,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,266.73,2183.424,fee schedule,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,185.92,2035.968,fee schedule,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,265.17,2031.36,fee schedule,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,307.53,2399.232,fee schedule,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,307.93,2175.744,fee schedule,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,305.58,2443.008,fee schedule,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,64.4315,416.02,fee schedule,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,974.592,fee schedule,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,1050.624,fee schedule,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,195.33,1198.848,fee schedule,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1460.736,fee schedule,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,1721.088,fee schedule,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,372.27,2188.8,fee schedule,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2114.304,fee schedule,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1297.2,,,1297.2,399.86,2233.344,fee schedule,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1297.2,,,1297.2,399.86,2233.344,fee schedule,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1297.2,,,1297.2,399.86,2233.344,fee schedule,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,791.06,,,791.06,331.811,2051.3855,fee schedule,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,791.06,,,791.06,399.86,2051.3855,fee schedule,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,791.06,,,791.06,395.12,2051.3855,fee schedule,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,791.06,,,791.06,399.86,2051.3855,fee schedule,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1865.69,,,1865.69,399.86,4977.9345,fee schedule,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1865.69,,,1865.69,399.86,4977.9345,fee schedule,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,38.165,416.02,fee schedule,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,68.697,416.02,fee schedule,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,57.472,416.02,fee schedule,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,31.2055,416.02,fee schedule,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,379.405,1297.92,fee schedule,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,39.961,416.02,fee schedule,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,38.3895,416.02,fee schedule,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,28.9605,416.02,fee schedule,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,298.8095,1022.208,fee schedule,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,50.5125,416.02,fee schedule,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,42.655,416.02,fee schedule,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1322.496,fee schedule,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,68.697,416.02,fee schedule,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.982,416.02,fee schedule,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,28.9605,416.02,fee schedule,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,736.512,fee schedule,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,193.37,1065.984,fee schedule,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1506.048,fee schedule,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1032.96,fee schedule,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,2217.984,fee schedule,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,371.09,2254.848,fee schedule,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2414.592,fee schedule,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,204.76,2333.952,fee schedule,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1867.69,,,1867.69,340.49,2414.592,fee schedule,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2350.08,fee schedule,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,49.839,416.02,fee schedule,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,49.839,416.02,fee schedule,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.4325,416.02,fee schedule,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.4325,416.02,fee schedule,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,581.376,fee schedule,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1241.088,fee schedule,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,47.8185,416.02,fee schedule,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,47.8185,416.02,fee schedule,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.084,416.02,fee schedule,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,58.37,416.02,fee schedule,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,382.548,1308.672,fee schedule,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,44.6755,416.02,fee schedule,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,51.8595,416.02,fee schedule,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,30.7565,416.02,fee schedule,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,29.185,416.02,fee schedule,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1020.2995,fee schedule,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,35.471,416.02,fee schedule,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,36.818,416.02,fee schedule,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.533,416.02,fee schedule,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,43.104,416.02,fee schedule,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,743.424,fee schedule,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,196.51,758.016,fee schedule,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1461.504,fee schedule,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,903.168,fee schedule,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,2178.048,fee schedule,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,372.66,1840.128,fee schedule,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2350.08,fee schedule,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,205.15,2310.144,fee schedule,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1867.69,,,1867.69,345.98,2317.824,fee schedule,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2379.264,fee schedule,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1295.69,,,1295.69,399.86,2290.176,fee schedule,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1295.69,,,1295.69,399.86,2290.176,fee schedule,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1295.69,,,1295.69,399.86,2290.176,fee schedule,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.084,416.02,fee schedule,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,92.045,416.02,fee schedule,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,1112.832,fee schedule,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,194.55,1218.048,fee schedule,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1580.544,fee schedule,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,329.339098,1982.208,fee schedule,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1040.64,fee schedule,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,142.38,1050.624,fee schedule,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,204.61123,1513.728,fee schedule,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,204.61123,1629.696,fee schedule,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,1810.176,fee schedule,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,3902.208,fee schedule,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2072.064,fee schedule,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1301.76,,,1301.76,301.425681,1878.528,fee schedule,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1301.76,,,1301.76,301.425681,1878.528,fee schedule,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1301.76,,,1301.76,301.425681,1878.528,fee schedule,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,76.026473,753.408,fee schedule,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,128.66,671.232,fee schedule,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,259.7465,888.576,other,SI=N Exclusions 
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,703.488,fee schedule,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,194.1925,664.32,fee schedule,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,128.66,2264.832,fee schedule,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,183.14,907.776,fee schedule,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,822.528,fee schedule,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,1350.144,fee schedule,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,1026.048,other,SI=N Exclusions 
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,64.8805,416.02,other,SI=N Exclusions 
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,797.184,other,SI=N Exclusions 
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.08,669.696,other,SI=N Exclusions 
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,260.23,2237.184,other,SI=N Exclusions 
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,141.6595,484.608,other,SI=N Exclusions 
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1890.816,other,SI=N Exclusions 
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,134.4755,499.422,fee schedule,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,1595.904,fee schedule,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1020.2995,fee schedule,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,399.86,2172.672,fee schedule,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1020.2995,fee schedule,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,171.069,646.6965,fee schedule,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,171.069,646.6965,fee schedule,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,568.91,,,568.91,121.679,1393.3385,fee schedule,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1989.5,,,1989.5,399.86,5136.771,fee schedule,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,237.819698,1301.76,fee schedule,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,285.115,975.36,other,SI=N Exclusions 
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,88.902,1706.496,fee schedule,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,88.902,1706.496,fee schedule,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,102.5965,2030.592,fee schedule,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,102.5965,2030.592,fee schedule,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.2045,836,other,SI=N Exclusions 
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.2045,836,other,SI=N Exclusions 
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.2,,,168.2,19.0825,575,fee schedule,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.2,,,168.2,19.0825,575,fee schedule,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,58.819,669.696,fee schedule,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,58.819,669.696,fee schedule,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,58.819,780.288,fee schedule,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,58.819,780.288,fee schedule,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,57.921,824.064,fee schedule,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,57.921,824.064,fee schedule,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2536.61,,,2536.61,399.86,2536.61118,fee schedule,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,1321.728,fee schedule,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2717.184,other,SI=N Exclusions 
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,92.2695,416.02,fee schedule,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,709.02,,,709.02,399.86,4120.349,fee schedule,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,4120.349,fee schedule,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,709.02,,,709.02,399.86,4120.349,fee schedule,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,709.02,,,709.02,399.86,3400.704,fee schedule,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,709.02,,,709.02,367.731,1602.0655,fee schedule,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,1947.648,other,SI=N Exclusions 
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,260.23,8249.769,fee schedule,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,260.23,3665.664,other,SI=N Exclusions 
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,105.7395,416.02,other,SI=N Exclusions 
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,505.64,,,505.64,324.627,1110.528,fee schedule,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,434.03,,,434.03,294.544,1007.616,fee schedule,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,288.34,,,288.34,189.7025,648.96,fee schedule,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,251.22,,,251.22,167.028,571.392,fee schedule,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,2241.024,other,SI=N Exclusions 
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,2215.68,other,SI=N Exclusions 
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,681.984,other,SI=N Exclusions 
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,681.984,other,SI=N Exclusions 
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,195.08,765.696,fee schedule,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,568.91,,,568.91,237.819698,1497.6,fee schedule,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,568.91,,,568.91,220.908,1393.3385,fee schedule,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,85.759,416.02,fee schedule,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.024,836,other,SI=N Exclusions 
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.024,836,other,SI=N Exclusions 
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.024,836,other,SI=N Exclusions 
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.739,836,other,SI=N Exclusions 
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.739,836,other,SI=N Exclusions 
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.739,836,other,SI=N Exclusions 
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,712.704,fee schedule,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1565.65,,,1565.65,81.08,1703.424,fee schedule,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,602.98,,,602.98,189.029,836,fee schedule,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.4105,575,other,Unlisted Codes
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,97.2085,416.02,fee schedule,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,99.678,416.02,fee schedule,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,93.6165,416.02,fee schedule,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.4325,416.02,fee schedule,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,103.4945,416.02,fee schedule,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.5545,416.02,fee schedule,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,58.5945,416.02,fee schedule,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,82.616,416.02,fee schedule,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,77.4525,416.02,fee schedule,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,456.96,fee schedule,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,64.8805,416.02,fee schedule,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,50.288,416.02,other,SI=N Exclusions 
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,94.5145,416.02,fee schedule,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.086513,547.584,other,SI=N Exclusions 
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,162.7625,646.6965,fee schedule,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions 
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,68.0235,416.02,fee schedule,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,460.8,fee schedule,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,79.6975,416.02,fee schedule,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,98.5555,416.02,fee schedule,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,80.371,416.02,fee schedule,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,65.105,416.02,fee schedule,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,443.904,fee schedule,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,32.777,416.02,fee schedule,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,81.9425,416.02,fee schedule,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,199.512292,772.608,fee schedule,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,81.0445,416.02,fee schedule,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,74.534,416.02,fee schedule,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,102.5965,416.02,fee schedule,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,90.0245,416.02,fee schedule,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,61.2885,416.02,fee schedule,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,89.8,416.02,fee schedule,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,56.7985,416.02,fee schedule,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,288.53,,,288.53,152.8845,775.5705,fee schedule,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,56.3495,416.02,other,SI=N Exclusions 
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,103.27,416.02,other,SI=N Exclusions 
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,166.37,666.624,other,SI=N Exclusions 
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.473,416.02,other,SI=N Exclusions 
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,135.598,463.872,other,SI=N Exclusions 
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,116.9645,416.02,other,SI=N Exclusions 
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,71.391,416.02,other,SI=N Exclusions 
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,116.291,416.02,other,SI=N Exclusions 
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1383.168,other,SI=N Exclusions 
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.344499,1341.696,other,SI=N Exclusions 
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.344499,1347.84,other,SI=N Exclusions 
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,139.8635,575,other,SI=N Exclusions 
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2374.656,other,SI=N Exclusions 
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,189.029,836,fee schedule,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,189.029,836,fee schedule,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1238.08,,,1238.08,399.547552,1936.896,fee schedule,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1238.08,,,1238.08,399.547552,1936.896,fee schedule,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1232.02,,,1232.02,399.547552,2548.224,fee schedule,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1232.02,,,1232.02,399.547552,2548.224,fee schedule,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,72.0645,416.02,other,Non Reimbursable Rates
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,88.2285,416.02,other,Non Reimbursable Rates
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44.94,,,44.94,22.99364,416.02,fee schedule,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,167.5,,,167.5,88.2285,416.02,fee schedule,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,214.37,,,214.37,90.800319,416.02,fee schedule,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,177.13,,,177.13,90.800319,416.02,fee schedule,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,58.819,416.02,fee schedule,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,48.941,416.02,fee schedule,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,112.699,416.02,fee schedule,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,112.699,416.02,fee schedule,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,441.6,fee schedule,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,25.593,416.02,fee schedule,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,267.439885,1847.808,fee schedule,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,210.2,55.676,416.02,percent of total billed charges,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,210.2,55.676,416.02,percent of total billed charges,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,209.9075,1076.394,fee schedule,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,142.1085,1076.394,fee schedule,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,220.459,1076.394,fee schedule,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,235.5005,1397.122,fee schedule,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,38.3895,416.02,other,SI=N Exclusions 
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,353.5875,1209.6,fee schedule,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,304.6465,1076.394,fee schedule,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,358.69,1457.664,fee schedule,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,3675.6585,fee schedule,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,314.9735,1077.504,fee schedule,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,314.9735,1077.504,fee schedule,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,147.9455,1076.394,fee schedule,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,217.9895,1076.394,fee schedule,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,240.4395,1397.122,fee schedule,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,2239.93036,fee schedule,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,270.5225,1076.394,fee schedule,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,310.708,1076.394,fee schedule,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,310.708,1397.122,fee schedule,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,176.906,1076.394,fee schedule,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,234.1535,1076.394,fee schedule,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,188.131,1076.394,fee schedule,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,399.86,1596.672,fee schedule,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,200.4785,1076.394,fee schedule,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,214.173,1076.394,fee schedule,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,215.969,1076.394,fee schedule,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,246.501,1076.394,fee schedule,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,200.4785,1076.394,fee schedule,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,214.622,1076.394,fee schedule,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3319.26,,,3319.26,399.86,3675.6585,fee schedule,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3319.26,,,3319.26,399.86,3675.6585,fee schedule,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3319.26,,,3319.26,399.86,3675.6585,fee schedule,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3319.26,,,3319.26,399.86,3675.6585,fee schedule,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,954.41,,,954.41,356.057,1218.048,fee schedule,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,954.41,,,954.41,375.1395,1283.328,fee schedule,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,172.1915,1076.394,fee schedule,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,143.68,1076.394,fee schedule,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,212.377,1397.122,fee schedule,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,202.499,1076.394,fee schedule,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,336.5255,1397.122,fee schedule,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,399.86,2076.672,fee schedule,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,356.7305,1397.122,fee schedule,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3713.88,,,3713.88,399.86,3755.52,fee schedule,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,399.86,1973.76,fee schedule,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,205.642,1397.122,fee schedule,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,3675.6585,fee schedule,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,290.054,1076.394,fee schedule,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,271.645,1397.122,fee schedule,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,201.8255,1397.122,fee schedule,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,189.7025,1076.394,fee schedule,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,194.6415,1076.394,fee schedule,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,3675.6585,fee schedule,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,399.86,3675.6585,fee schedule,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,3675.6585,fee schedule,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,275.4615,1076.394,fee schedule,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3713.88,,,3713.88,399.86,3982.848,fee schedule,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3713.88,,,3713.88,399.86,5302.272,fee schedule,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3713.88,,,3713.88,399.86,5917.44,fee schedule,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3291.82,,,3291.82,399.86,3675.6585,fee schedule,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3291.82,,,3291.82,399.86,3675.6585,fee schedule,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3734.2,,,3734.2,399.86,4124.5085,fee schedule,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.5735,416.02,other,SI=N Exclusions 
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,264.04,,,264.04,175.559,691.5815,fee schedule,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.58,,,4.58,2.29,24.576,fee schedule,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.75,,,13.75,6.286,21.504,fee schedule,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,294.44,,,294.44,160.742,549.888,fee schedule,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6.87,,,6.87,3.33,18.432,fee schedule,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.16,,,5.16,2.4,34.56,fee schedule,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,638.24,,,638.24,39.73,1313.895373,fee schedule,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8.59,,,8.59,4.35,61.44,fee schedule,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14.89,,,14.89,6.78,24.576,fee schedule,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.88,,,10.88,5.6125,19.2,fee schedule,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.09,,,36.09,18.77,98.304,fee schedule,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.18,,,13.18,6.51,121.344,fee schedule,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16.04,,,16.04,6.5105,24.43,fee schedule,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16.61,,,16.61,7.4085,25.344,fee schedule,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28.07,,,28.07,14.71,119.04,fee schedule,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.41,,,50.41,26.37,193.536,fee schedule,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54.42,,,54.42,27.838,95.232,fee schedule,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.99,,,168.99,64.4315,241.472,fee schedule,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.3,,,58.3,6.25,92.88556,fee schedule,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.072,274.944,fee schedule,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,313.59,,,313.59,2.842,549.235176,fee schedule,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,5.5,93.463636,fee schedule,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,5.85,274.176,fee schedule,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,5.29,274.176,fee schedule,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,121.77,,,121.77,3.05,195.186327,fee schedule,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,3.05,65.28,fee schedule,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,313.59,,,313.59,3.91,549.235176,fee schedule,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,9.71,238.848,fee schedule,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,313.59,,,313.59,3.91,549.235176,fee schedule,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,7.91,218.112,fee schedule,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.31,272.64,fee schedule,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.072,274.176,fee schedule,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.45,274.176,fee schedule,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,1.862,274.176,fee schedule,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,1.302,263.69806,fee schedule,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,1.932,416.02,fee schedule,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,1.932,93.463636,fee schedule,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,313.59,,,313.59,1.54,499.62884,fee schedule,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171.41,,,171.41,2.702,274.944,fee schedule,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,2.072,608.812631,fee schedule,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19.63,,,19.63,2.31,238.848,fee schedule,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.31,416.02,fee schedule,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.31,416.02,fee schedule,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,2.31,238.848,fee schedule,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.68,229.632,other,Unlisted Codes
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26.35,,,26.35,11.674,39.936,fee schedule,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.3,,,58.3,47.145,416.02,fee schedule,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.3,,,58.3,34.124,116.736,fee schedule,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.49,,,23.49,12.32,44.544,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,139.93,,,139.93,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,139.93,,,139.93,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,139.93,,,139.93,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,139.93,,,139.93,139.93,1690.176,fee schedule,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2075.55,,,2075.55,389.10344,4791.979,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94.43,,,94.43,0.5,416.02,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94.43,,,94.43,0.5,416.02,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94.43,,,94.43,0.5,416.02,fee schedule,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72.39,,,72.39,43.3285,416.02,fee schedule,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.3885,416.02,other,SI=N Exclusions 
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,94.08,24.9195,416.02,percent of total billed charges,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,268.35,,,268.35,0.5,671.54688,fee schedule,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,268.35,,,268.35,0.5,671.54688,fee schedule,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.48,416.02,other,SI=N Exclusions 
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.48,416.02,other,SI=N Exclusions 
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,34.799745,416.02,other,SI=N Exclusions 
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,34.799745,416.02,other,SI=N Exclusions 
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.07683,416.02,other,SI=N Exclusions 
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.07683,416.02,other,SI=N Exclusions 
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,368.98,,,368.98,0.5,881.02656,fee schedule,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,368.98,,,368.98,0.5,881.02656,fee schedule,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35.97,,,35.97,0.5,416.02,fee schedule,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35.97,,,35.97,0.5,416.02,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,350.14,,,350.14,91.911626,1316.02176,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,350.14,,,350.14,91.911626,1316.02176,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,350.14,,,350.14,91.911626,1316.02176,fee schedule,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,298.04,,,298.04,0.5,843.5712,fee schedule,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.43,,,81.43,0.5,416.02,fee schedule,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.43,,,81.43,0.5,416.02,fee schedule,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.135995,416.02,other,SI=N Exclusions 
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.135995,416.02,other,SI=N Exclusions 
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,54.47,416.02,other,SI=N Exclusions 
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,54.47,416.02,other,SI=N Exclusions 
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions 
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions 
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions 
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions 
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions 
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions 
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,219.45,,,219.45,0.5,566.10816,fee schedule,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,219.45,,,219.45,0.5,566.10816,fee schedule,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,116.81,,,116.81,0.5,416.02,fee schedule,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,116.81,,,116.81,0.5,416.02,fee schedule,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,188.67,,,188.67,0.5,492.14208,fee schedule,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,188.67,,,188.67,0.5,492.14208,fee schedule,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.3,,,168.3,0.5,416.02,fee schedule,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.3,,,168.3,0.5,416.02,fee schedule,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,620.59,,,620.59,252.787,1055.807021,fee schedule,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,620.59,,,620.59,398.4875,1363.2,fee schedule,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,3012.096,fee schedule,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,3012.096,fee schedule,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,168.824,1592,fee schedule,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,920,RC,,,outpatient,,,1360,952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,305.32,1592,fee schedule,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,417.63,0.5,417.629472,percent of total billed charges,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,417.63,0.5,417.629472,percent of total billed charges,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,17.96,416.02,fee schedule,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,163,975.36,fee schedule,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,163,677.376,fee schedule,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,123.475,422.4,fee schedule,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,34.7975,416.02,fee schedule,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,34.7975,416.02,fee schedule,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,34.7975,416.02,fee schedule,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,142.97,534.528,fee schedule,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,50.5125,416.02,other,SI=N Exclusions 
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,60.3905,416.02,fee schedule,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,51.635,416.02,fee schedule,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,61.17,416.02,fee schedule,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,32.328,416.02,fee schedule,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,29.634,416.02,fee schedule,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,116.5155,416.02,fee schedule,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17.44,,,17.44,7.8575,416.02,fee schedule,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,21.3275,416.02,fee schedule,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,28.0625,416.02,fee schedule,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,80.5955,416.02,fee schedule,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,112.25,416.02,fee schedule,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,114.7195,416.02,fee schedule,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,25.593,416.02,fee schedule,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,128.12716,479.602522,fee schedule,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40.5,,,40.5,26.042,416.02,fee schedule,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,66.67,,,66.67,36.369,416.02,fee schedule,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,84.99,559.872,fee schedule,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.01,416.02,other,SI=N Exclusions 
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,358.32,,,358.32,128.12716,662.784,fee schedule,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,358.32,,,358.32,128.12716,662.784,fee schedule,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,13488.384,fee schedule,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13488.384,other,SI=N Exclusions 
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,25715.712,fee schedule,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,25231.872,other,SI=N Exclusions 
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,25024.512,fee schedule,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,20484.864,other,SI=N Exclusions 
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,20097.792,other,SI=N Exclusions 
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20484.864,fee schedule,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,20097.792,other,SI=N Exclusions 
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,19712.256,fee schedule,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,20097.792,other,SI=N Exclusions 
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,232.133,997.822944,fee schedule,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,232.133,997.822944,fee schedule,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,717.67,,,717.67,292.299,999.936,fee schedule,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,717.67,,,717.67,399.86,1540.608,fee schedule,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,717.67,,,717.67,399.86,1540.608,fee schedule,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,173.5385,593.664,other,SI=N Exclusions 
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,2138.88,other,SI=N Exclusions 
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,2138.88,other,SI=N Exclusions 
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,169.4975,1592,other,SI=N Exclusions 
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,169.4975,1592,other,SI=N Exclusions 
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,13233.408,fee schedule,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,16809.6787,fee schedule,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,16809.6787,fee schedule,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,25.49469,416.02,fee schedule,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16.68,,,16.68,6.286,416.02,fee schedule,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,108.8825,479.602522,fee schedule,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,25.49469,416.02,fee schedule,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.8,,,13.8,4.939,416.02,fee schedule,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,84.459332,416.02,fee schedule,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,66.75974,416.02,fee schedule,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52.32,,,52.32,14.1435,416.02,fee schedule,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,41.157815,934.656,fee schedule,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,41.157815,1442.304,fee schedule,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,41.157815,416.02,fee schedule,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.4,,,23.4,23.39896,416.02,fee schedule,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1223.3,fee schedule,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1223.3,fee schedule,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,281.81,1040.64,fee schedule,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,281.81,1040.64,fee schedule,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1034.496,fee schedule,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1034.496,fee schedule,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1034.496,fee schedule,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,267.439885,943.104,fee schedule,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,267.439885,943.104,fee schedule,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,125.9445,465.66,fee schedule,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,125.9445,465.66,fee schedule,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,125.9445,465.66,fee schedule,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1354.752,fee schedule,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1354.752,fee schedule,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,336.9745,1152.768,fee schedule,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.024,416.02,other,SI=N Exclusions 
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,72.5135,416.02,other,SI=N Exclusions 
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,86.208,416.02,other,SI=N Exclusions 
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,135.906309,571.392,other,SI=N Exclusions 
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1062.912,fee schedule,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1062.912,fee schedule,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1370.88,fee schedule,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1370.88,fee schedule,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.661,597.504,other,SI=N Exclusions 
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,241.7865,827.136,other,SI=N Exclusions 
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,7870.4,fee schedule,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,7870.4,fee schedule,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,7870.4,fee schedule,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7960.32,other,SI=N Exclusions 
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2532.39,fee schedule,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2532.39,fee schedule,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1952.256,other,SI=N Exclusions 
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,228.541,1592,other,SI=N Exclusions 
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,114.495,1592,other,SI=N Exclusions 
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,228.541,1592,other,SI=N Exclusions 
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions 
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5638.7,other,SI=N Exclusions 
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1575.168,other,SI=N Exclusions 
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,40899.072,fee schedule,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,40899.072,fee schedule,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,40542.72,fee schedule,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,40542.72,fee schedule,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1501.69,,,1501.69,399.86,12978.432,fee schedule,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6909.98,other,SI=N Exclusions 
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4525.056,other,SI=N Exclusions 
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2361.6,other,SI=N Exclusions 
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1253.16,,,1253.16,399.86,2367.744,fee schedule,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,620.59,,,620.59,399.86,2367.744,fee schedule,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10671.09667,other,SI=N Exclusions 
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,382.23,,,382.23,73.54,934.656,fee schedule,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,161.05,,,161.05,57.2475,416.02,fee schedule,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,161.05,,,161.05,60.8395,416.02,fee schedule,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,199.512292,702.72,fee schedule,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,119.991125,702.72,fee schedule,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,255.2565,873.216,fee schedule,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,96.086,686,fee schedule,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,213.724,731.136,fee schedule,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,135.906309,702.72,fee schedule,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,121.132463,686,fee schedule,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,135.906309,775.5705,fee schedule,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,199.512292,702.72,fee schedule,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,99.0045,686,fee schedule,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,135.906309,686,fee schedule,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,135.906309,686,fee schedule,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,119.991125,702.72,fee schedule,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,170.171,686,fee schedule,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,170.171,686,fee schedule,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,119.991125,702.72,fee schedule,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,183.192,686,fee schedule,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,93.841,686,fee schedule,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,199.512292,702.72,fee schedule,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,86.8815,686,fee schedule,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,119.991125,686,fee schedule,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,66.2275,416.02,fee schedule,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,100.127,479.602522,fee schedule,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,163,710.4,fee schedule,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,88.004,416.02,fee schedule,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,88.004,416.02,fee schedule,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75.42,,,75.42,40.859,416.02,fee schedule,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,261.18,,,261.18,59.92,416.02,fee schedule,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,98.67,479.602522,fee schedule,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,66.2275,416.02,fee schedule,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,59.4925,416.02,other,SI=N Exclusions 
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.123,416.02,other,SI=N Exclusions 
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,416.02,other,SI=N Exclusions 
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,43.553,416.02,fee schedule,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,43.553,416.02,other,SI=N Exclusions 
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.74,416.02,other,Unlisted Codes
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,330.64,,,330.64,185.6615,635.136,fee schedule,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,330.64,,,330.64,185.6615,635.136,fee schedule,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,330.64,,,330.64,185.6615,635.136,fee schedule,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,634.38,,,634.38,370.2005,1266.432,fee schedule,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,634.38,,,634.38,355.8325,1217.28,fee schedule,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,634.38,,,634.38,355.8325,1217.28,fee schedule,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,182.294,623.616,fee schedule,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,215.071,735.744,fee schedule,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,157.3745,538.368,fee schedule,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,176.457,603.648,fee schedule,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,151.5375,518.4,fee schedule,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,572.13,151.5375,829.50194,percent of total billed charges,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.817,570,other,SI=N Exclusions 
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.817,570,other,SI=N Exclusions 
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,30.083,570,other,SI=N Exclusions 
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,30.083,570,other,SI=N Exclusions 
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.4295,570,other,SI=N Exclusions 
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.4295,570,other,SI=N Exclusions 
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,94.4,583.68,fee schedule,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,94.4,570,fee schedule,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,94.4,570,fee schedule,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,197.3355,675.072,other,SI=N Exclusions 
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,156.252,534.528,other,SI=N Exclusions 
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,74.983,416.02,fee schedule,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51.64,,,51.64,19.9805,585.854902,fee schedule,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,93.841,416.02,fee schedule,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51.64,,,51.64,29.634,585.854902,fee schedule,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.45,,,81.45,41.0835,416.02,fee schedule,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.4705,416.02,other,SI=N Exclusions 
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.45,,,81.45,16.16,416.02,fee schedule,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,74.983,416.02,fee schedule,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,69.3705,416.02,fee schedule,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51.64,,,51.64,23.5725,416.02,fee schedule,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.0235,416.02,other,SI=N Exclusions 
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.45,,,81.45,49.839,416.02,fee schedule,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,155.1295,530.688,fee schedule,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,162.538,556.032,fee schedule,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.45,,,81.45,41.9815,585.854902,fee schedule,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,70.143083,517.481916,fee schedule,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,147.4965,585.854902,fee schedule,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,34.385146,416.02,fee schedule,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,14.38,416.02,per diem,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,27.6135,416.02,per diem,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,14.73,416.02,per diem,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,20.02,416.02,per diem,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27.77,,,27.77,14.44,416.02,fee schedule,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,14.44,416.02,per diem,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,62.16,,,62.16,30.33,416.02,fee schedule,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,30.33,416.02,per diem,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70.88,,,70.88,25.8175,416.02,fee schedule,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.31,,,56.31,27.89,416.02,fee schedule,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,27.89,416.02,per diem,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.96,,,36.96,18.56,416.02,fee schedule,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.96,,,36.96,18.56,416.02,fee schedule,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171.91,,,171.91,58.37,416.02,fee schedule,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171.91,,,171.91,58.37,416.02,fee schedule,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171.91,,,171.91,58.37,416.02,fee schedule,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,117.4,,,117.4,51.8595,416.02,fee schedule,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,23.348,416.02,per diem,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,68.29,,,68.29,34.45,416.02,fee schedule,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.34,,,58.34,23.797,416.02,fee schedule,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31.99,,,31.99,11.674,416.02,fee schedule,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.635,416.02,other,SI=N Exclusions 
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions 
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions 
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,81.0445,416.02,other,SI=N Exclusions 
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions 
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,74.085,416.02,other,SI=N Exclusions 
HC Phlebotomy,PX-94000006,CDM,99195,CPT,300,RC,,,outpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,70.044,416.02,fee schedule,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.01,,,100.01,82.56,416.02,fee schedule,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,150,,,150,126.37,473.871,fee schedule,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,253.92,,,253.92,179.35,693.026,fee schedule,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,331.4,,,331.4,146.954008,985.784,fee schedule,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18.12,,,18.12,18.1184,416.02,fee schedule,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18.12,,,18.12,18.1184,416.02,fee schedule,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18.12,,,18.12,18.1184,416.02,fee schedule,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,761,RC,,,outpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.24,,,50.24,50.2428,416.02,fee schedule,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,761,RC,,,outpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.24,,,50.24,50.2428,416.02,fee schedule,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,761,RC,,,outpatient,,,373,261.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.24,,,50.24,50.2428,416.02,fee schedule,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.47,,,100.47,90.68,416.02,fee schedule,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.47,,,100.47,90.68,416.02,fee schedule,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,154.91,,,154.91,104.8415,416.02,fee schedule,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,154.91,,,154.91,104.8415,416.02,fee schedule,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,218.39,,,218.39,169.273,685.583,fee schedule,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,218.39,,,218.39,169.273,685.583,fee schedule,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1008.74,,,1008.74,318.748996,2424.576,fee schedule,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1008.74,,,1008.74,318.748996,2424.576,fee schedule,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,204.5195,699.648,other,SI=N Exclusions 
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,204.5195,699.648,other,SI=N Exclusions 
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45.5,,,45.5,31.31797,416.02,fee schedule,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45.5,,,45.5,31.31797,416.02,fee schedule,
TPN ELECTROLYTES IV CONC,RX-110242,CDM,25000001,HCPCS,250,RC,00409-5779-01,NDC,outpatient,20,ML,32.85,22.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.84,0.74534,528.0548,percent of total billed charges,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,21.01,0.74534,528.0548,percent of total billed charges,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,99999-0003-10,NDC,outpatient,10,ML,15.37,10.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.03,0.74534,528.0548,percent of total billed charges,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.18,0.74534,528.0548,percent of total billed charges,
TALC 4 G PL POWD,RX-142785,CDM,25000001,HCPCS,250,RC,62327-0444-44,NDC,outpatient,1,UN,623,436.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,528.05,0.74534,528.0548,percent of total billed charges,
TALC 4 G PL POWD,RX-142785,CDM,25000001,HCPCS,250,RC,62327-0444-04,NDC,outpatient,1,UN,623,436.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,528.05,0.74534,528.0548,percent of total billed charges,
HYPERLYTE-CR IV CONC,RX-150262,CDM,25000001,HCPCS,250,RC,00409-5779-11,NDC,outpatient,20,ML,32.85,22.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.84,0.74534,528.0548,percent of total billed charges,
HYPERLYTE-CR IV CONC,RX-150262,CDM,25000001,HCPCS,250,RC,00409-5779-01,NDC,outpatient,20,ML,32.85,22.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.84,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0202-06,NDC,outpatient,1000,ML,162.85,113.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,138.03,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0206-04,NDC,outpatient,2000,ML,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,239.87,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0206-01,NDC,outpatient,2000,ML,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,239.87,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0202-01,NDC,outpatient,1000,ML,162.85,113.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,138.03,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0214-01,NDC,outpatient,2000,ML,238.5,166.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,202.15,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0210-01,NDC,outpatient,1000,ML,153.95,107.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,130.49,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0214-04,NDC,outpatient,2000,ML,238.5,166.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,202.15,0.74534,528.0548,percent of total billed charges,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0210-06,NDC,outpatient,1000,ML,153.95,107.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,130.49,0.74534,528.0548,percent of total billed charges,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-152285,CDM,25000001,HCPCS,250,RC,00338-0184-04,NDC,outpatient,2000,ML,274.1,191.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,232.33,0.74534,528.0548,percent of total billed charges,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-152285,CDM,25000001,HCPCS,250,RC,00338-0184-01,NDC,outpatient,2000,ML,274.1,191.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,232.33,0.74534,528.0548,percent of total billed charges,
CLINIMIX/DEXTROSE (8/10) 8 % IV SOLN,RX-152286,CDM,25000001,HCPCS,250,RC,00338-0194-04,NDC,outpatient,2000,ML,229.6,160.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,194.61,0.74534,528.0548,percent of total billed charges,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-156196,CDM,25000001,HCPCS,250,RC,00517-9302-01,NDC,outpatient,1,ML,76.19,53.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,64.58,0.74534,528.0548,percent of total billed charges,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-156196,CDM,25000001,HCPCS,250,RC,00517-9302-25,NDC,outpatient,1,ML,76.19,53.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,64.58,0.74534,528.0548,percent of total billed charges,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-02,NDC,outpatient,250,ML,57.17,40.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,48.46,0.74534,528.0548,percent of total billed charges,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-03,NDC,outpatient,500,ML,69.4,48.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,58.82,0.74534,528.0548,percent of total billed charges,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-06,NDC,outpatient,250,ML,57.17,40.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,48.46,0.74534,528.0548,percent of total billed charges,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-07,NDC,outpatient,500,ML,69.4,48.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,58.82,0.74534,528.0548,percent of total billed charges,
PRISMASOL BGK 4/0/1.2 32-4-1.2 MEQ/L EC SOLN,RX-156745,CDM,25000001,HCPCS,250,RC,24571-0114-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,249.94,0.74534,528.0548,percent of total billed charges,
MORPHINE SULFATE 100 MG IN D5W 100 ML PREMIX,RX-166979,CDM,25000001,HCPCS,250,RC,99999-0003-25,NDC,outpatient,100,ML,48.85,34.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,41.41,0.74534,528.0548,percent of total billed charges,
ALUMINUM POTASSIUM SULFATE POWD,RX-21429,CDM,25000001,HCPCS,250,RC,24357-0300-30,NDC,outpatient,10,GR,267.27,187.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,226.54,0.74534,528.0548,percent of total billed charges,
TROPHAMINE 10 % IV SOLN,RX-25798,CDM,25000001,HCPCS,250,RC,00264-1933-10,NDC,outpatient,500,ML,198.45,138.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,168.21,0.74534,528.0548,percent of total billed charges,
GENTAMICIN IV SYRINGE 4 MG/ML (PEDIATRIC),RX-400058,CDM,25000001,HCPCS,250,RC,99999-0000-52,NDC,outpatient,10,ML,50.94,35.658,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,43.18,0.74534,528.0548,percent of total billed charges,
GENTAMICIN IV SYRINGE 4 MG/ML (PEDIATRIC),RX-400058,CDM,25000001,HCPCS,250,RC,99999-0001-20,NDC,outpatient,5,ML,36.18,25.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,30.67,0.74534,528.0548,percent of total billed charges,
AMINOCAPROIC ACID INFUSION (OPEN HEART),RX-400081,CDM,25000001,HCPCS,250,RC,99999-0000-86,NDC,outpatient,150,ML,97.97,68.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,83.04,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,25000001,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,22.27,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,25000001,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.1,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.81,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,6.43,4.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.45,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.81,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.32,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.14,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.32,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.14,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00338-0013-04,NDC,outpatient,1000,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.71,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.76,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.05,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.05,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.45,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-20,NDC,outpatient,20,ML,4.84,3.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.1,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.76,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-23,NDC,outpatient,20,ML,4.84,3.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.1,0.74534,528.0548,percent of total billed charges,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.93,0.74534,528.0548,percent of total billed charges,
SUGAMMADEX SODIUM 100 MG/ML IV SOLN WRAPPER,RX-4080830,CDM,25000001,HCPCS,250,RC,00006-5423-02,NDC,outpatient,2,ML,533.12,373.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,451.87,0.74534,528.0548,percent of total billed charges,
SUGAMMADEX SODIUM 100 MG/ML IV SOLN WRAPPER,RX-4080830,CDM,25000001,HCPCS,250,RC,00006-5423-12,NDC,outpatient,2,ML,533.12,373.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,451.87,0.74534,528.0548,percent of total billed charges,
DEXMEDETOMIDINE HCL IN NACL 4 MCG/ML IV SOLN WRAPPER,RX-4080915,CDM,25000001,HCPCS,250,RC,00338-9557-12,NDC,outpatient,100,ML,89.43,62.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,75.8,0.74534,528.0548,percent of total billed charges,
DILTIAZEM 100 MG IN 100 ML D5W BATCHED INFUSION,RX-4080938,CDM,25000001,HCPCS,250,RC,99999-0000-30,NDC,outpatient,100,ML,48.09,33.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,40.76,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % CRRT SOLN,RX-4081079,CDM,25000001,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,17.92,0.74534,528.0548,percent of total billed charges,
SODIUM CHLORIDE 0.9 % CRRT SOLN,RX-4081079,CDM,25000001,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.1,0.74534,528.0548,percent of total billed charges,
FAMOTIDINE IN NS (NEO/PEDI) SYRINGE 0.4 MG/ML,RX-4081338,CDM,25000001,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.54,0.74534,528.0548,percent of total billed charges,
PANTOPRAZOLE 80 MG/100 ML BOLUS/LOADING DOSE PREMIX,RX-4081495,CDM,25000001,HCPCS,250,RC,99999-0004-21,NDC,outpatient,100,ML,36.56,25.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,30.99,0.74534,528.0548,percent of total billed charges,
CARDIOPLEGIA SOLN HIGH POTASSIUM 60 MEQ + MG 65 MEQ IN 500 ML OF NS,RX-4081526,CDM,25000001,HCPCS,250,RC,99999-0004-32,NDC,outpatient,500,ML,78.75,55.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,66.75,0.74534,528.0548,percent of total billed charges,
VANCOMYCIN INTRAOSSEOUS 500 MG/50 ML NS SYR,RX-4081621,CDM,25000001,HCPCS,250,RC,99999-0004-52,NDC,outpatient,50,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,28.81,0.74534,528.0548,percent of total billed charges,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,25000001,HCPCS,250,RC,00338-0644-06,NDC,outpatient,2000,ML,122.8,85.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,104.09,0.74534,528.0548,percent of total billed charges,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,25000001,HCPCS,250,RC,00338-0644-04,NDC,outpatient,1000,ML,78.3,54.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,66.37,0.74534,528.0548,percent of total billed charges,
ZINC OXIDE 16 % EX OINT,RX-109467,CDM,25900001,HCPCS,259,RC,62103-0333-04,NDC,outpatient,113,GR,20.62,14.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,17.48,0.222255,1203.778472,percent of total billed charges,
GLYCOPYRROLATE-FORMOTEROL 9-4.8 MCG/ACT IN AERO,RX-135283,CDM,25900001,HCPCS,259,RC,00310-4600-12,NDC,outpatient,10.7,GR,1420.22,994.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1203.78,0.222255,1203.778472,percent of total billed charges,
MULTIVITAMINS PLUS IRON CHILD 18 MG ORAL CHEW,RX-138485,CDM,25900001,HCPCS,259,RC,16500-0079-09,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,0.84,0.222255,1203.778472,percent of total billed charges,
MULTIVITAMINS PLUS IRON CHILD 18 MG ORAL CHEW,RX-138485,CDM,25900001,HCPCS,259,RC,16500-0599-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,0.84,0.222255,1203.778472,percent of total billed charges,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148710,CDM,25900001,HCPCS,259,RC,00436-0946-16,NDC,outpatient,473,ML,52.63,36.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,44.61,0.222255,1203.778472,percent of total billed charges,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148710,CDM,25900001,HCPCS,259,RC,39328-0062-50,NDC,outpatient,473,ML,44.21,30.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,37.47,0.222255,1203.778472,percent of total billed charges,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,62559-0431-30,NDC,outpatient,30,GR,76.9,53.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,65.18,0.222255,1203.778472,percent of total billed charges,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,69315-0312-28,NDC,outpatient,28,GR,33.65,23.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,28.52,0.222255,1203.778472,percent of total billed charges,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,10631-0407-01,NDC,outpatient,28.35,GR,38.36,26.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,32.51,0.222255,1203.778472,percent of total billed charges,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,64980-0324-30,NDC,outpatient,30,GR,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,21.84,0.222255,1203.778472,percent of total billed charges,
PRAMOXINE HCL (PERIANAL) 1 % EX FOAM,RX-150306,CDM,25900001,HCPCS,259,RC,51862-0180-15,NDC,outpatient,15,GR,166.95,116.865,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,141.51,0.222255,1203.778472,percent of total billed charges,
HYDROCORT-PRAMOXINE (PERIANAL) 1-1 % EX FOAM,RX-150328,CDM,25900001,HCPCS,259,RC,00037-6822-10,NDC,outpatient,10,GR,761.13,532.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,645.13,0.222255,1203.778472,percent of total billed charges,
PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG ORAL TABS,RX-155613,CDM,25900001,HCPCS,259,RC,76385-0102-01,NDC,outpatient,1,UN,5.96,4.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.05,0.222255,1203.778472,percent of total billed charges,
ZANAMIVIR 5 MG/ACT IN AEPB,RX-160595,CDM,25900001,HCPCS,259,RC,00173-0681-01,NDC,outpatient,20,UN,240.22,168.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,203.61,0.222255,1203.778472,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % EX CREA,RX-16299,CDM,25900001,HCPCS,259,RC,45802-0358-03,NDC,outpatient,28,GR,4.62,3.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.92,0.222255,1203.778472,percent of total billed charges,
GLYCERIN (LIQUID) 2.8 G RE SUPP,RX-163739,CDM,25900001,HCPCS,259,RC,00132-0190-12,NDC,outpatient,4,ML,3,2.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.54,0.222255,1203.778472,percent of total billed charges,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,00121-0530-05,NDC,outpatient,5,ML,13.51,9.457,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.45,0.222255,1203.778472,percent of total billed charges,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,63739-0157-70,NDC,outpatient,5,ML,6.5,4.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.51,0.222255,1203.778472,percent of total billed charges,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,63739-0157-10,NDC,outpatient,5,ML,6.5,4.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.51,0.222255,1203.778472,percent of total billed charges,
PSYLLIUM 25 % ORAL PACK,RX-166710,CDM,25900001,HCPCS,259,RC,37000-0023-04,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1.85,0.222255,1203.778472,percent of total billed charges,
PSYLLIUM 25 % ORAL PACK,RX-166710,CDM,25900001,HCPCS,259,RC,37000-0023-10,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1.85,0.222255,1203.778472,percent of total billed charges,
ASTROGLIDE EX GEL,RX-23759,CDM,25900001,HCPCS,259,RC,15594-0010-07,NDC,outpatient,66.5,GR,20.13,14.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,17.06,0.222255,1203.778472,percent of total billed charges,
CORN STARCH EX POWD,RX-28839,CDM,25900001,HCPCS,259,RC,00316-0233-25,NDC,outpatient,71,GR,13.91,9.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.79,0.222255,1203.778472,percent of total billed charges,
GLYCERIN (LAXATIVE) 5.4 GM/DOSE RE ENEM,RX-37495,CDM,25900001,HCPCS,259,RC,00132-0185-82,NDC,outpatient,7.5,ML,3.54,2.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3,0.222255,1203.778472,percent of total billed charges,
GLYCERIN (LAXATIVE) 5.4 GM/DOSE RE ENEM,RX-37495,CDM,25900001,HCPCS,259,RC,00132-0185-01,NDC,outpatient,7.5,ML,3.54,2.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3,0.222255,1203.778472,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG/ML ORAL SOLN,RX-3782,CDM,25900001,HCPCS,259,RC,39328-0047-15,NDC,outpatient,15,ML,86.71,60.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,73.5,0.222255,1203.778472,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG/ML ORAL SOLN,RX-3782,CDM,25900001,HCPCS,259,RC,54838-0506-15,NDC,outpatient,15,ML,121.96,85.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,103.37,0.222255,1203.778472,percent of total billed charges,
GENTAMICIN FORTIFIED EYE SOLUTION 14 MG/ML,RX-4080014,CDM,25900001,HCPCS,259,RC,99999-0001-32,NDC,outpatient,7,ML,17.67,12.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14.98,0.222255,1203.778472,percent of total billed charges,
LACTULOSE ENEMA IN STERILE WATER 1000 ML,RX-4080406,CDM,25900001,HCPCS,259,RC,,,outpatient,1000,ML,16.47,11.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.96,0.222255,1203.778472,percent of total billed charges,
LACTULOSE ENEMA IN SODIUM CHLORIDE 0.9 % 1000 ML,RX-4080407,CDM,25900001,HCPCS,259,RC,99999-0001-00,NDC,outpatient,1000,ML,16.47,11.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.96,0.222255,1203.778472,percent of total billed charges,
WITCH HAZEL-GLYCERIN EX PADS WRAPPER,RX-4080503,CDM,25900001,HCPCS,259,RC,50289-3250-01,NDC,outpatient,40,UN,9.62,6.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.15,0.222255,1203.778472,percent of total billed charges,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3011-05,NDC,outpatient,5,ML,18.29,12.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,15.5,0.222255,1203.778472,percent of total billed charges,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3013-05,NDC,outpatient,10,ML,24.12,16.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.44,0.222255,1203.778472,percent of total billed charges,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3015-05,NDC,outpatient,20,ML,33.02,23.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.99,0.222255,1203.778472,percent of total billed charges,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3012-05,NDC,outpatient,5,ML,18.29,12.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,15.5,0.222255,1203.778472,percent of total billed charges,
CLONIDINE NEONATAL SUSPENSION 5 MCG/ML,RX-4080796,CDM,25900001,HCPCS,259,RC,99999-0001-04,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,0.84,0.222255,1203.778472,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLN WRAPPER,RX-4081075,CDM,25900001,HCPCS,259,RC,99999-0000-64,NDC,outpatient,2.5,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.54,0.222255,1203.778472,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLN WRAPPER,RX-4081075,CDM,25900001,HCPCS,259,RC,65628-0206-05,NDC,outpatient,2.5,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.54,0.222255,1203.778472,percent of total billed charges,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,41100-0015-11,NDC,outpatient,15,ML,31.71,22.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,26.88,0.222255,1203.778472,percent of total billed charges,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,41100-0811-23,NDC,outpatient,15,ML,25.17,17.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,21.33,0.222255,1203.778472,percent of total billed charges,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,49348-0130-27,NDC,outpatient,30,ML,16.69,11.683,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14.15,0.222255,1203.778472,percent of total billed charges,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,00904-7006-35,NDC,outpatient,15,ML,6.41,4.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.43,0.222255,1203.778472,percent of total billed charges,
SULFUR PRECIPITATED POWD,RX-7576,CDM,25900001,HCPCS,259,RC,38779-0098-08,NDC,outpatient,500,GR,142.38,99.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,120.68,0.222255,1203.778472,percent of total billed charges,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,124.32,0.222255,1203.778472,percent of total billed charges,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,78.39,0.222255,1203.778472,percent of total billed charges,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,99.87,0.222255,1203.778472,percent of total billed charges,
DESMOPRESSIN ACE REFRIGERATED 0.01 % NA SOLN,RX-9749,CDM,25900001,HCPCS,259,RC,55566-2400-00,NDC,outpatient,2.5,ML,1134.27,793.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,961.41,0.222255,1203.778472,percent of total billed charges,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,outpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,72,other,SI=N Exclusions 
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.491,94.4,other,SI=N Exclusions 
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,outpatient,,,113,79.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.3685,90.4,other,SI=N Exclusions 
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,outpatient,,,80,56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.96,64,other,SI=N Exclusions 
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,outpatient,,,79,55.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.7355,63.2,other,SI=N Exclusions 
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,outpatient,,,267,186.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,59.9415,213.6,other,SI=N Exclusions 
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,outpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,72,other,SI=N Exclusions 
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,outpatient,,,282,197.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.309,225.6,other,SI=N Exclusions 
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,outpatient,,,268,187.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.166,214.4,other,SI=N Exclusions 
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,outpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.5335,226.4,other,SI=N Exclusions 
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,outpatient,,,285,199.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.9825,228,other,SI=N Exclusions 
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,64.4315,229.6,other,SI=N Exclusions 
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,outpatient,,,307,214.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.9215,245.6,other,SI=N Exclusions 
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,outpatient,,,423,296.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.9635,338.4,other,SI=N Exclusions 
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,outpatient,,,438,306.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,98.331,350.4,other,SI=N Exclusions 
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,outpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,423.2,other,SI=N Exclusions 
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,outpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,423.2,other,SI=N Exclusions 
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,outpatient,,,816,571.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,183.192,652.8,other,SI=N Exclusions 
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,outpatient,,,3884,2718.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,871.958,3107.2,other,SI=N Exclusions 
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,outpatient,,,4891,3423.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1098.0295,3912.8,other,SI=N Exclusions 
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,outpatient,,,5242,3669.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1176.829,4193.6,other,SI=N Exclusions 
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,outpatient,,,5466,3826.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1227.117,4372.8,other,SI=N Exclusions 
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,outpatient,,,667,466.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,149.7415,533.6,other,SI=N Exclusions 
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,outpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.2485,282.4,other,SI=N Exclusions 
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,outpatient,,,327,228.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,73.4115,261.6,other,SI=N Exclusions 
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,outpatient,,,390,273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,87.555,312,other,SI=N Exclusions 
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,outpatient,,,707,494.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,158.7215,565.6,other,SI=N Exclusions 
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,outpatient,,,144,100.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,122.05,32.328,122.0544,percent of total billed charges,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,222.07,58.819,222.0712,percent of total billed charges,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,outpatient,,,272,190.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,230.55,61.064,230.5472,percent of total billed charges,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,259.37,68.697,259.3656,percent of total billed charges,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,outpatient,,,377,263.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,319.55,84.6365,319.5452,percent of total billed charges,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,outpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,399.22,105.7395,399.2196,percent of total billed charges,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,outpatient,,,490,343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,415.32,110.005,415.324,percent of total billed charges,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,outpatient,,,939,657.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,795.9,210.8055,795.8964,percent of total billed charges,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,outpatient,,,88,61.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,74.59,19.756,74.5888,percent of total billed charges,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,outpatient,,,95,66.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,80.52,21.3275,80.522,percent of total billed charges,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,outpatient,,,108,75.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,91.54,24.246,91.5408,percent of total billed charges,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,outpatient,,,128,89.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,108.49,28.736,108.4928,percent of total billed charges,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,163.59,43.3285,163.5868,percent of total billed charges,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,outpatient,,,195,136.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,165.28,43.7775,165.282,percent of total billed charges,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,outpatient,,,225,157.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,190.71,50.5125,190.71,percent of total billed charges,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,302.59,80.1465,302.5932,percent of total billed charges,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,302.59,80.1465,302.5932,percent of total billed charges,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,302.59,80.1465,302.5932,percent of total billed charges,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,outpatient,,,374,261.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,317,83.963,317.0024,percent of total billed charges,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,outpatient,,,396,277.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,335.65,88.902,335.6496,percent of total billed charges,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,outpatient,,,402,281.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,340.74,90.249,340.7352,percent of total billed charges,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,outpatient,,,409,286.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,346.67,91.8205,346.6684,percent of total billed charges,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,outpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,354.3,93.841,354.2968,percent of total billed charges,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,outpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,353.45,93.6165,353.4492,percent of total billed charges,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,outpatient,,,446,312.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,378.03,100.127,378.0296,percent of total billed charges,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,outpatient,,,451,315.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,382.27,101.2495,382.2676,percent of total billed charges,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,394.98,104.617,394.9816,percent of total billed charges,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,394.98,104.617,394.9816,percent of total billed charges,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,outpatient,,,470,329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,398.37,105.515,398.372,percent of total billed charges,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,outpatient,,,488,341.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,413.63,109.556,413.6288,percent of total billed charges,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,outpatient,,,516,361.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,437.36,115.842,437.3616,percent of total billed charges,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,outpatient,,,519,363.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,439.9,116.5155,439.9044,percent of total billed charges,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,outpatient,,,523,366.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,443.29,117.4135,443.2948,percent of total billed charges,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,outpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,458.55,121.4545,458.5516,percent of total billed charges,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,outpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,458.55,121.4545,458.5516,percent of total billed charges,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,outpatient,,,556,389.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,471.27,124.822,471.2656,percent of total billed charges,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,outpatient,,,674,471.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,571.28,151.313,571.2824,percent of total billed charges,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,outpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,588.23,155.803,588.2344,percent of total billed charges,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,outpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,588.23,155.803,588.2344,percent of total billed charges,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,outpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,588.23,155.803,588.2344,percent of total billed charges,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,outpatient,,,703,492.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,595.86,157.8235,595.8628,percent of total billed charges,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,outpatient,,,719,503.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,609.42,161.4155,609.4244,percent of total billed charges,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,outpatient,,,722,505.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,611.97,162.089,611.9672,percent of total billed charges,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,outpatient,,,731,511.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,619.6,164.1095,619.5956,percent of total billed charges,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,outpatient,,,765,535.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,648.41,171.7425,648.414,percent of total billed charges,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,outpatient,,,776,543.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,657.74,174.212,657.7376,percent of total billed charges,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,outpatient,,,776,543.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,657.74,174.212,657.7376,percent of total billed charges,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,716.22,189.7025,716.222,percent of total billed charges,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,716.22,189.7025,716.222,percent of total billed charges,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,716.22,189.7025,716.222,percent of total billed charges,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,outpatient,,,895,626.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,758.6,200.9275,758.602,percent of total billed charges,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,outpatient,,,895,626.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,758.6,200.9275,758.602,percent of total billed charges,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,700.97,185.6615,700.9652,percent of total billed charges,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,outpatient,,,939,657.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,795.9,210.8055,795.8964,percent of total billed charges,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,outpatient,,,979,685.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,829.8,219.7855,829.8004,percent of total billed charges,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,outpatient,,,1581,1106.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1340.06,354.9345,1340.0556,percent of total billed charges,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,outpatient,,,1581,1106.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1340.06,354.9345,1340.0556,percent of total billed charges,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,outpatient,,,1136,795.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,962.87,255.032,962.8736,percent of total billed charges,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,outpatient,,,1269,888.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1075.6,284.8905,1075.6044,percent of total billed charges,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,outpatient,,,1319,923.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1117.98,296.1155,1117.9844,percent of total billed charges,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,outpatient,,,1399,979.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1185.79,314.0755,1185.7924,percent of total billed charges,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,outpatient,,,1408,985.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1193.42,316.096,1193.4208,percent of total billed charges,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,outpatient,,,2027,1418.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1718.09,455.0615,1718.0852,percent of total billed charges,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,outpatient,,,2219,1553.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1880.82,498.1655,1880.8244,percent of total billed charges,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,outpatient,,,2602,1821.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2205.46,584.149,2205.4552,percent of total billed charges,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,outpatient,,,2943,2060.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2494.49,660.7035,2494.4868,percent of total billed charges,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,outpatient,,,5565,3895.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4716.89,1249.3425,4716.894,percent of total billed charges,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,outpatient,,,5512,3858.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4671.97,1237.444,4671.9712,percent of total billed charges,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,outpatient,,,4120,2884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3492.11,924.94,3492.112,percent of total billed charges,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,outpatient,,,5512,3858.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4671.97,1237.444,4671.9712,percent of total billed charges,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,outpatient,,,1349,944.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1143.41,302.8505,1143.4124,percent of total billed charges,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,outpatient,,,39,27.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,33.06,8.7555,33.0564,percent of total billed charges,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,outpatient,,,1238,866.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1049.33,277.931,1049.3288,percent of total billed charges,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,outpatient,,,1113,779.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,943.38,249.8685,943.3788,percent of total billed charges,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,outpatient,,,1887,1320.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1599.42,423.6315,1599.4212,percent of total billed charges,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,outpatient,,,1097,767.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,929.82,246.2765,929.8172,percent of total billed charges,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,outpatient,,,1504,1052.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1274.79,337.648,1274.7904,percent of total billed charges,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,outpatient,,,319,223.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,270.38,71.6155,270.3844,percent of total billed charges,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,outpatient,,,462,323.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,391.59,103.719,391.5912,percent of total billed charges,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,outpatient,,,1077,753.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,912.87,241.7865,912.8652,percent of total billed charges,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,outpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,411.93,109.107,411.9336,percent of total billed charges,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,outpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,378.88,100.3515,378.8772,percent of total billed charges,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,outpatient,,,1332,932.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1129,299.034,1129.0032,percent of total billed charges,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,outpatient,,,297,207.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,251.74,66.6765,251.7372,percent of total billed charges,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,outpatient,,,537,375.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,455.16,120.5565,455.1612,percent of total billed charges,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,outpatient,,,565,395.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,478.89,126.8425,478.894,percent of total billed charges,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,outpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,353.45,93.6165,353.4492,percent of total billed charges,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,outpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,349.21,92.494,349.2112,percent of total billed charges,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,outpatient,,,691,483.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,585.69,155.1295,585.6916,percent of total billed charges,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,outpatient,,,506,354.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,428.89,113.597,428.8856,percent of total billed charges,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,outpatient,,,424,296.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,359.38,95.188,359.3824,percent of total billed charges,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,outpatient,,,594,415.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,503.47,133.353,503.4744,percent of total billed charges,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,outpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,448.38,118.7605,448.3804,percent of total billed charges,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,outpatient,,,906,634.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,767.93,203.397,767.9256,percent of total billed charges,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,outpatient,,,648,453.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,549.24,145.476,549.2448,percent of total billed charges,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,outpatient,,,990,693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,839.12,222.255,839.124,percent of total billed charges,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,outpatient,,,865,605.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,733.17,194.1925,733.174,percent of total billed charges,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,outpatient,,,433,303.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,367.01,97.2085,367.0108,percent of total billed charges,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,outpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,333.95,88.453,333.9544,percent of total billed charges,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,outpatient,,,606,424.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,513.65,136.047,513.6456,percent of total billed charges,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,outpatient,,,700,490,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,593.32,157.15,593.32,percent of total billed charges,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,outpatient,,,2205,1543.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1868.96,495.0225,1868.958,percent of total billed charges,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,outpatient,,,1336,935.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1132.39,299.932,1132.3936,percent of total billed charges,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,outpatient,,,1094,765.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,927.27,245.603,927.2744,percent of total billed charges,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,outpatient,,,1188,831.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1006.95,266.706,1006.9488,percent of total billed charges,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,outpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,978.13,259.073,978.1304,percent of total billed charges,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,outpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,978.13,259.073,978.1304,percent of total billed charges,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,outpatient,,,785,549.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,665.37,176.2325,665.366,percent of total billed charges,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,outpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,660.28,174.8855,660.2804,percent of total billed charges,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,outpatient,,,1191,833.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1009.49,267.3795,1009.4916,percent of total billed charges,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,outpatient,,,983,688.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,833.19,220.6835,833.1908,percent of total billed charges,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,outpatient,,,457,319.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,387.35,102.5965,387.3532,percent of total billed charges,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,outpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,399.22,105.7395,399.2196,percent of total billed charges,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,outpatient,,,465,325.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,394.13,104.3925,394.134,percent of total billed charges,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,outpatient,,,823,576.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,697.57,184.7635,697.5748,percent of total billed charges,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,outpatient,,,619,433.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,524.66,138.9655,524.6644,percent of total billed charges,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,outpatient,,,795,556.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,673.84,178.4775,673.842,percent of total billed charges,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,outpatient,,,722,505.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,611.97,162.089,611.9672,percent of total billed charges,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,outpatient,,,245,171.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,207.66,55.0025,207.662,percent of total billed charges,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,outpatient,,,954,667.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,808.61,214.173,808.6104,percent of total billed charges,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,outpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,978.13,259.073,978.1304,percent of total billed charges,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,outpatient,,,497,347.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,421.26,111.5765,421.2572,percent of total billed charges,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,outpatient,,,251,175.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,212.75,56.3495,212.7476,percent of total billed charges,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,outpatient,,,408,285.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,345.82,91.596,345.8208,percent of total billed charges,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,outpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,378.88,100.3515,378.8772,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,outpatient,,,359,251.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,304.29,80.5955,304.2884,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,outpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,264.45,70.044,264.4512,percent of total billed charges,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,outpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,264.45,70.044,264.4512,percent of total billed charges,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,outpatient,,,622,435.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,527.21,139.639,527.2072,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,outpatient,,,552,386.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,467.88,123.924,467.8752,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,outpatient,,,1221,854.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1034.92,274.1145,1034.9196,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,outpatient,,,3772,2640.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3197.15,846.814,3197.1472,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,outpatient,,,1954,1367.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1656.21,438.673,1656.2104,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,outpatient,,,3806,2664.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3225.97,854.447,3225.9656,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,outpatient,,,661,462.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,560.26,148.3945,560.2636,percent of total billed charges,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,outpatient,,,570,399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,483.13,127.965,483.132,percent of total billed charges,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,outpatient,,,570,399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,483.13,127.965,483.132,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,outpatient,,,3385,2369.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2869.13,759.9325,2869.126,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,outpatient,,,3185,2229.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2699.61,715.0325,2699.606,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,outpatient,,,380,266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,322.09,85.31,322.088,percent of total billed charges,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,outpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,660.28,174.8855,660.2804,percent of total billed charges,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,outpatient,,,330,231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,279.71,74.085,279.708,percent of total billed charges,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,outpatient,,,382,267.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,323.78,85.759,323.7832,percent of total billed charges,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,outpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,379.72,100.576,379.7248,percent of total billed charges,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,outpatient,,,473,331.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,400.91,106.1885,400.9148,percent of total billed charges,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,425.5,112.699,425.4952,percent of total billed charges,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,557.72,147.721,557.7208,percent of total billed charges,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,outpatient,,,661,462.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,560.26,148.3945,560.2636,percent of total billed charges,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,outpatient,,,703,492.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,595.86,157.8235,595.8628,percent of total billed charges,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,outpatient,,,745,521.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,631.46,167.2525,631.462,percent of total billed charges,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,outpatient,,,785,549.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,665.37,176.2325,665.366,percent of total billed charges,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,outpatient,,,901,630.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,763.69,202.2745,763.6876,percent of total billed charges,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,775.55,205.4175,775.554,percent of total billed charges,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,outpatient,,,1117,781.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,946.77,250.7665,946.7692,percent of total billed charges,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,outpatient,,,2560,1792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2169.86,574.72,2169.856,percent of total billed charges,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,outpatient,,,2560,1792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2169.86,574.72,2169.856,percent of total billed charges,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2520.76,667.663,2520.7624,percent of total billed charges,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,outpatient,,,3011,2107.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2552.12,675.9695,2552.1236,percent of total billed charges,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,outpatient,,,3011,2107.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2552.12,675.9695,2552.1236,percent of total billed charges,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,outpatient,,,3165,2215.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2682.65,710.5425,2682.654,percent of total billed charges,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,outpatient,,,3418,2392.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2897.1,767.341,2897.0968,percent of total billed charges,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,outpatient,,,3462,2423.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2934.39,777.219,2934.3912,percent of total billed charges,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,outpatient,,,6597,4617.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5591.62,1481.0265,5591.6172,percent of total billed charges,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,557.72,147.721,557.7208,percent of total billed charges,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,557.72,147.721,557.7208,percent of total billed charges,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,outpatient,,,1232,862.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1044.24,276.584,1044.2432,percent of total billed charges,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,outpatient,,,1750,1225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1483.3,392.875,1483.3,percent of total billed charges,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,outpatient,,,3933,2753.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3333.61,882.9585,3333.6108,percent of total billed charges,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,outpatient,,,4114,2879.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3487.03,923.593,3487.0264,percent of total billed charges,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,outpatient,,,4461,3122.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3781.14,1001.4945,3781.1436,percent of total billed charges,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,394.98,104.617,394.9816,percent of total billed charges,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2520.76,667.663,2520.7624,percent of total billed charges,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2520.76,667.663,2520.7624,percent of total billed charges,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2520.76,667.663,2520.7624,percent of total billed charges,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,outpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,900.15,238.419,900.1512,percent of total billed charges,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,outpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,900.15,238.419,900.1512,percent of total billed charges,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,outpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,900.15,238.419,900.1512,percent of total billed charges,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,outpatient,,,1445,1011.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1224.78,324.4025,1224.782,percent of total billed charges,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,outpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,379.72,100.576,379.7248,percent of total billed charges,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,294.12,77.9015,294.1172,percent of total billed charges,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,outpatient,,,1065,745.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,902.69,239.0925,902.694,percent of total billed charges,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,outpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,299.2,79.2485,299.2028,percent of total billed charges,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,outpatient,,,1413,989.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1197.66,317.2185,1197.6588,percent of total billed charges,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,outpatient,,,1290,903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1093.4,289.605,1093.404,percent of total billed charges,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,outpatient,,,1290,903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1093.4,289.605,1093.404,percent of total billed charges,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,outpatient,,,2135,1494.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1809.63,479.3075,1809.626,percent of total billed charges,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,outpatient,,,745,521.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,631.46,167.2525,631.462,percent of total billed charges,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,222.07,58.819,222.0712,percent of total billed charges,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,222.07,58.819,222.0712,percent of total billed charges,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,outpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,299.2,79.2485,299.2028,percent of total billed charges,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,outpatient,,,1286,900.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1090.01,288.707,1090.0136,percent of total billed charges,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,outpatient,,,649,454.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,550.09,145.7005,550.0924,percent of total billed charges,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,outpatient,,,758,530.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,642.48,170.171,642.4808,percent of total billed charges,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,outpatient,,,1063,744.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,901,238.6435,900.9988,percent of total billed charges,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,outpatient,,,1093,765.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,926.43,245.3785,926.4268,percent of total billed charges,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,outpatient,,,1217,851.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1031.53,273.2165,1031.5292,percent of total billed charges,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,outpatient,,,1355,948.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1148.5,304.1975,1148.498,percent of total billed charges,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,outpatient,,,1398,978.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1184.94,313.851,1184.9448,percent of total billed charges,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,outpatient,,,1474,1031.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1249.36,330.913,1249.3624,percent of total billed charges,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,outpatient,,,1499,1049.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1270.55,336.5255,1270.5524,percent of total billed charges,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,outpatient,,,1773,1241.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1502.79,398.0385,1502.7948,percent of total billed charges,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,outpatient,,,1585,1109.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1343.45,355.8325,1343.446,percent of total billed charges,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,outpatient,,,1636,1145.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1386.67,367.282,1386.6736,percent of total billed charges,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,outpatient,,,1749,1224.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1482.45,392.6505,1482.4524,percent of total billed charges,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,outpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,401.76,106.413,401.7624,percent of total billed charges,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,outpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,401.76,106.413,401.7624,percent of total billed charges,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,outpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,401.76,106.413,401.7624,percent of total billed charges,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,outpatient,,,328,229.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,278.01,73.636,278.0128,percent of total billed charges,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,outpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,411.93,109.107,411.9336,percent of total billed charges,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,outpatient,,,1773,1241.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1502.79,398.0385,1502.7948,percent of total billed charges,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,outpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,588.23,155.803,588.2344,percent of total billed charges,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,outpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,401.76,106.413,401.7624,percent of total billed charges,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,outpatient,,,475,332.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,402.61,106.6375,402.61,percent of total billed charges,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,outpatient,,,1710,1197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1449.4,383.895,1449.396,percent of total billed charges,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,outpatient,,,1327,928.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1124.77,297.9115,1124.7652,percent of total billed charges,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,outpatient,,,1327,928.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1124.77,297.9115,1124.7652,percent of total billed charges,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,outpatient,,,1300,910,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1101.88,291.85,1101.88,percent of total billed charges,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,outpatient,,,32,22.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.12,7.184,27.1232,percent of total billed charges,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,outpatient,,,142,99.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,120.36,31.879,120.3592,percent of total billed charges,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,outpatient,,,157,109.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,133.07,35.2465,133.0732,percent of total billed charges,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,outpatient,,,152,106.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,128.84,34.124,128.8352,percent of total billed charges,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,outpatient,,,208,145.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,176.3,46.696,176.3008,percent of total billed charges,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,outpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,50.86,13.47,50.856,percent of total billed charges,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,outpatient,,,75,52.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,63.57,16.8375,63.57,percent of total billed charges,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,outpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,50.86,13.47,50.856,percent of total billed charges,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,outpatient,,,75,52.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,63.57,16.8375,63.57,percent of total billed charges,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,outpatient,,,99,69.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,83.91,22.2255,83.9124,percent of total billed charges,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,outpatient,,,140,98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,118.66,31.43,118.664,percent of total billed charges,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,outpatient,,,138,96.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,116.97,30.981,116.9688,percent of total billed charges,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,134.77,35.6955,134.7684,percent of total billed charges,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,outpatient,,,700,490,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,593.32,157.15,593.32,percent of total billed charges,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,outpatient,,,850,595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,720.46,190.825,720.46,percent of total billed charges,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,outpatient,,,1662,1163.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1408.71,373.119,1408.7112,percent of total billed charges,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,805.22,213.275,805.22,percent of total billed charges,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,outpatient,,,2924,2046.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2478.38,656.438,2478.3824,percent of total billed charges,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,outpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1017.12,269.4,1017.12,percent of total billed charges,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,outpatient,,,4262,2983.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3612.47,956.819,3612.4712,percent of total billed charges,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,outpatient,,,9166,6416.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,7769.1,2057.767,7769.1016,percent of total billed charges,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,outpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1017.12,269.4,1017.12,percent of total billed charges,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,outpatient,,,3749,2624.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3177.65,841.6505,3177.6524,percent of total billed charges,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,outpatient,,,5356,3749.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4539.75,1202.422,4539.7456,percent of total billed charges,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,outpatient,,,9641,6748.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8171.71,2164.4045,8171.7116,percent of total billed charges,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,outpatient,,,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,21.19,5.6125,21.19,percent of total billed charges,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,outpatient,,,22,15.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,18.65,4.939,18.6472,percent of total billed charges,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,outpatient,,,23,16.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,19.49,5.1635,19.4948,percent of total billed charges,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,outpatient,,,28,19.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,23.73,6.286,23.7328,percent of total billed charges,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,outpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24.58,6.5105,24.5804,percent of total billed charges,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,outpatient,,,33,23.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.97,7.4085,27.9708,percent of total billed charges,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,outpatient,,,38,26.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,32.21,8.531,32.2088,percent of total billed charges,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,outpatient,,,1500,1050,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1271.4,336.75,1271.4,percent of total billed charges,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,outpatient,,,101,70.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,85.61,22.6745,6652,percent of total billed charges,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,outpatient,,,569,398.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,482.28,127.7405,482.2844,percent of total billed charges,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,outpatient,,,569,398.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,482.28,127.7405,482.2844,percent of total billed charges,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,outpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24.58,6.5105,24.5804,percent of total billed charges,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,outpatient,,,7,4.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.93,1.5715,163,percent of total billed charges,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,outpatient,,,43,30.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,36.45,9.6535,163,percent of total billed charges,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,outpatient,,,171,119.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,144.94,38.3895,163,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,656.04,173.763,2998,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,136.46,36.1445,2998,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,22389.35,399.86,22389.354,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,622.99,165.0075,2998,percent of total billed charges,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,1477.69344,other,SI=N Exclusions 
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.30904,416.02,other,SI=N Exclusions 
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.850175,416.02,other,SI=N Exclusions 
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.025285,416.02,other,SI=N Exclusions 
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.025285,416.02,other,SI=N Exclusions 
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.025285,416.02,other,SI=N Exclusions 
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.025285,416.02,other,SI=N Exclusions 
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions 
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions 
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions 
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions 
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions 
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions 
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions 
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.401765,416.02,other,SI=N Exclusions 
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.401765,416.02,other,SI=N Exclusions 
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.99,416.02,other,SI=N Exclusions 
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions 
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions 
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions 
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions 
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions 
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions 
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions 
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions 
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions 
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions 
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions 
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions 
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.3553,416.02,other,SI=N Exclusions 
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.3553,416.02,other,SI=N Exclusions 
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.3553,416.02,other,SI=N Exclusions 
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.23,416.02,other,SI=N Exclusions 
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.98576,416.02,other,SI=N Exclusions 
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.98576,416.02,other,SI=N Exclusions 
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.94544,416.02,other,SI=N Exclusions 
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.94544,416.02,other,SI=N Exclusions 
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.94544,416.02,other,SI=N Exclusions 
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.94544,416.02,other,SI=N Exclusions 
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.121435,416.02,other,SI=N Exclusions 
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.121435,416.02,other,SI=N Exclusions 
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.692165,416.02,other,SI=N Exclusions 
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions 
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions 
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions 
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions 
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions 
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions 
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions 
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.206745,416.02,other,SI=N Exclusions 
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.206745,416.02,other,SI=N Exclusions 
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04041,416.02,other,SI=N Exclusions 
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04041,416.02,other,SI=N Exclusions 
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04041,416.02,other,SI=N Exclusions 
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04041,416.02,other,SI=N Exclusions 
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions 
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions 
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions 
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions 
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions 
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions 
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions 
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions 
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions 
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions 
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions 
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions 
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions 
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions 
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions 
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions 
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions 
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions 
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions 
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.913715,416.02,other,SI=N Exclusions 
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.913715,416.02,other,SI=N Exclusions 
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.913715,416.02,other,SI=N Exclusions 
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.913715,416.02,other,SI=N Exclusions 
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.67604,416.02,other,SI=N Exclusions 
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,416.02,other,SI=N Exclusions 
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,416.02,other,SI=N Exclusions 
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,416.02,other,SI=N Exclusions 
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.600005,416.02,other,SI=N Exclusions 
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.600005,416.02,other,SI=N Exclusions 
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.600005,416.02,other,SI=N Exclusions 
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.087465,416.02,other,SI=N Exclusions 
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.66833,416.02,other,SI=N Exclusions 
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.66833,416.02,other,SI=N Exclusions 
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.122795,416.02,other,SI=N Exclusions 
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.122795,416.02,other,SI=N Exclusions 
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.98009,416.02,other,SI=N Exclusions 
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions 
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions 
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions 
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions 
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions 
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions 
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions 
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions 
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions 
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions 
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.21357,416.02,other,SI=N Exclusions 
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions 
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions 
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions 
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions 
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions 
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.12,416.02,other,SI=N Exclusions 
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions 
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions 
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.994945,416.02,other,SI=N Exclusions 
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions 
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions 
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions 
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions 
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,291.097925,929.69805,other,SI=N Exclusions 
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions 
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions 
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions 
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions 
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions 
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions 
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions 
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions 
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions 
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions 
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions 
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions 
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions 
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions 
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions 
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.99,1.322305,17969.99175,percent of total billed charges,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions 
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.99,1.322305,17969.99175,percent of total billed charges,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions 
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions 
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions 
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions 
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions 
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions 
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions 
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,72522.399,other,SI=N Exclusions 
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,72522.399,other,SI=N Exclusions 
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions 
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14791.55,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14791.55,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14791.55,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14791.55,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions 
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions 
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions 
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,247.50227,1378.95936,other,SI=N Exclusions 
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,247.50227,1378.95936,other,SI=N Exclusions 
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,247.50227,1378.95936,other,SI=N Exclusions 
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions 
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions 
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions 
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions 
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,144.095325,460.20645,other,SI=N Exclusions 
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions 
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23012.49024,other,SI=N Exclusions 
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23012.49024,other,SI=N Exclusions 
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23012.49024,other,SI=N Exclusions 
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23012.49024,other,SI=N Exclusions 
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions 
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions 
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions 
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions 
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions 
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions 
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions 
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions 
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions 
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions 
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions 
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions 
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions 
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions 
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions 
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions 
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions 
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions 
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.06164,416.02,other,SI=N Exclusions 
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.06164,416.02,other,SI=N Exclusions 
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.06164,416.02,other,SI=N Exclusions 
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.06164,416.02,other,SI=N Exclusions 
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions 
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions 
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46419.072,other,SI=N Exclusions 
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46419.072,other,SI=N Exclusions 
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46419.072,other,SI=N Exclusions 
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46419.072,other,SI=N Exclusions 
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions 
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions 
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions 
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions 
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions 
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions 
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions 
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2621.49888,other,SI=N Exclusions 
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2621.49888,other,SI=N Exclusions 
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2621.49888,other,SI=N Exclusions 
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2621.49888,other,SI=N Exclusions 
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions 
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions 
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions 
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions 
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7592.15526,other,SI=N Exclusions 
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7592.15526,other,SI=N Exclusions 
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7592.15526,other,SI=N Exclusions 
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions 
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions 
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions 
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions 
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions 
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions 
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions 
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions 
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions 
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions 
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions 
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions 
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions 
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions 
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions 
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions 
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6381.888,other,SI=N Exclusions 
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42246.09,,,42246.09,399.86,42246.08608,fee schedule,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions 
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions 
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions 
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions 
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions 
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions 
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions 
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12724.19328,other,SI=N Exclusions 
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions 
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions 
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions 
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,170.294475,582.5664,other,SI=N Exclusions 
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.890315,416.02,other,SI=N Exclusions 
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.890315,416.02,other,SI=N Exclusions 
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.890315,416.02,other,SI=N Exclusions 
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.890315,416.02,other,SI=N Exclusions 
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions 
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions 
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1487.02215,other,SI=N Exclusions 
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1724.02,399.86,1724.0184,percent of total billed charges,
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1479.06,267.439885,1479.062,percent of total billed charges,
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2573.31,399.86,2573.3136,percent of total billed charges,
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,77.228,836,other,SI=N Exclusions 
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.84,,,0.84,0.71,921.95328,fee schedule,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-51,NDC,outpatient,1,UN,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions 
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-60,NDC,outpatient,1,UN,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions 
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-00,NDC,outpatient,1,UN,7.54,5.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions 
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-55,NDC,outpatient,1,UN,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions 
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-10,NDC,outpatient,1,UN,7.54,5.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions 
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.4,836.83584,other,SI=N Exclusions 
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.39,416.02,other,SI=N Exclusions 
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,,,,,3.39,416.02,other,SI=N Exclusions 
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.39,416.02,other,SI=N Exclusions 
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,,,,,3.39,416.02,other,SI=N Exclusions 
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.31,416.02,other,SI=N Exclusions 
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.31,416.02,other,SI=N Exclusions 
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.31,416.02,other,SI=N Exclusions 
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.36,1148.18304,other,SI=N Exclusions 
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.36,1148.18304,other,SI=N Exclusions 
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5136.79872,other,SI=N Exclusions 
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5136.79872,other,SI=N Exclusions 
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5136.79872,other,SI=N Exclusions 
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,182.24,5164.04736,other,SI=N Exclusions 
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,182.24,5164.04736,other,SI=N Exclusions 
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,182.24,5164.04736,other,SI=N Exclusions 
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions 
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41430.25152,other,SI=N Exclusions 
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41430.25152,other,SI=N Exclusions 
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41430.25152,other,SI=N Exclusions 
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41430.25152,other,SI=N Exclusions 
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,177.26,5164.08576,other,SI=N Exclusions 
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,177.26,5164.08576,other,SI=N Exclusions 
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.39,18739.8144,other,SI=N Exclusions 
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.39,18739.8144,other,SI=N Exclusions 
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.39,18739.8144,other,SI=N Exclusions 
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.39,18739.8144,other,SI=N Exclusions 
SARILUMAB 200 MG/1.14ML SC SOAJ,RX-143091,CDM,C9399,HCPCS,636,RC,00024-5922-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4927.7,399.86,4927.700596,percent of total billed charges,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21.76,,,21.76,18.2,1865.41824,fee schedule,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21.76,,,21.76,18.2,1865.41824,fee schedule,
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,25024.512,fee schedule,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,26025.216,other,SI=N Exclusions 
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,26025.216,fee schedule,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,26025.216,other,SI=N Exclusions 
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,26025.216,other,SI=N Exclusions 
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,185.6615,1592,other,SI=N Exclusions 
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,386.589,2141,fee schedule,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.349,1592,other,SI=N Exclusions 
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.3685,416.02,other,SI=N Exclusions 
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28.83,,,28.83,12.01,416.02,fee schedule,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4585,,,4585,22.6745,6652,per diem,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4585,,,4585,22.6745,6652,per diem,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4585,,,4585,104.83,6652,per diem,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1288.62,,,1288.62,399.86,7964.16,fee schedule,
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1288.62,,,1288.62,399.86,7964.16,fee schedule,
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1288.62,,,1288.62,399.86,7964.16,fee schedule,
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions 
HC Inter Devc Remote 30d,PX-48000092,CDM,G2066,HCPCS,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,100.02,26.491,416.02,percent of total billed charges,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.44,,,43.44,43.27,2936.50176,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1705.16,,,1705.16,336.23,7116.76416,fee schedule,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1705.16,,,1705.16,336.23,7116.76416,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions 
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions 
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions 
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions 
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions 
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.01,,,2.01,1.61,416.02,fee schedule,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.01,,,2.01,1.61,416.02,fee schedule,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,223.52,,,223.52,215.38,15801.64608,fee schedule,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,223.52,,,223.52,215.38,15801.64608,fee schedule,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,201.97,,,201.97,194.92,2044.28544,fee schedule,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.51,,,5.51,5.51,1270.70976,fee schedule,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.94,,,4.94,4.88,1606.272,fee schedule,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.94,,,4.94,4.88,1606.272,fee schedule,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.94,,,4.94,4.88,1606.272,fee schedule,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.71,,,11.71,2.98,4260,fee schedule,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.71,,,11.71,2.98,4260,fee schedule,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions 
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions 
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.51,416.02,other,SI=N Exclusions 
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.51,416.02,other,SI=N Exclusions 
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.51,416.02,other,SI=N Exclusions 
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.51,416.02,other,SI=N Exclusions 
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,34.84689,416.02,other,SI=N Exclusions 
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.97,,,11.97,11.13,416.02,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.33,,,23.33,23.33,974.33088,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.33,,,23.33,23.33,974.33088,fee schedule,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions 
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.82,416.02,other,SI=N Exclusions 
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.82,416.02,other,SI=N Exclusions 
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.82,416.02,other,SI=N Exclusions 
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.82,416.02,other,SI=N Exclusions 
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,174.58,,,174.58,174.58,1359.95136,fee schedule,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,174.58,,,174.58,174.58,1359.95136,fee schedule,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,174.58,,,174.58,174.58,1359.95136,fee schedule,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.38,416.02,other,SI=N Exclusions 
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54.15,,,54.15,50.93,4488.66816,fee schedule,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54.15,,,54.15,50.93,4488.66816,fee schedule,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.23144,416.02,other,SI=N Exclusions 
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.23144,416.02,other,SI=N Exclusions 
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.23144,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions 
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19.52,,,19.52,15.67,697.86624,fee schedule,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19.52,,,19.52,15.67,697.86624,fee schedule,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions 
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions 
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions 
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions 
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions 
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6.41,,,6.41,6.15,1343.87712,fee schedule,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.03,416.02,other,SI=N Exclusions 
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.03,416.02,other,SI=N Exclusions 
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.06,416.02,other,SI=N Exclusions 
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.06,416.02,other,SI=N Exclusions 
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7403.87,,,7403.87,60.43,12645.75744,fee schedule,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7403.87,,,7403.87,60.43,12645.75744,fee schedule,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.09,,,0.09,0.08,416.02,fee schedule,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.09,,,0.09,0.08,416.02,fee schedule,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.09,,,0.09,0.08,416.02,fee schedule,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.09,,,0.09,0.08,416.02,fee schedule,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.09,,,0.09,0.08,416.02,fee schedule,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.09,,,0.09,0.08,416.02,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1173.06,,,1173.06,399.86,2155.44576,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1173.06,,,1173.06,399.86,2155.44576,fee schedule,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.68951,416.02,other,SI=N Exclusions 
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.68951,416.02,other,SI=N Exclusions 
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.68951,416.02,other,SI=N Exclusions 
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.11,,,10.11,4.2921885,416.02,fee schedule,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.11,,,10.11,4.2921885,416.02,fee schedule,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.11,,,10.11,4.2921885,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.26,,,1.26,1.22,416.02,fee schedule,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.26,,,1.26,1.22,416.02,fee schedule,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8.23,,,8.23,7.54,500.98176,fee schedule,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions 
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.96,416.02,other,SI=N Exclusions 
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.96,416.02,other,SI=N Exclusions 
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.65,416.02,other,SI=N Exclusions 
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.94,,,3.94,3.89,619.45344,fee schedule,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.94,,,3.94,3.89,619.45344,fee schedule,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.94,,,3.94,3.89,619.45344,fee schedule,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.94,,,3.94,3.89,619.45344,fee schedule,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.58,,,100.58,92.48,1248.58368,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.58,,,100.58,92.48,1248.58368,fee schedule,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.15189,416.02,other,SI=N Exclusions 
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.15189,416.02,other,SI=N Exclusions 
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.47,,,2.47,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.47,,,2.47,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.74271,416.02,other,SI=N Exclusions 
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.74271,416.02,other,SI=N Exclusions 
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.74271,416.02,other,SI=N Exclusions 
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.86,416.02,other,SI=N Exclusions 
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.86,416.02,other,SI=N Exclusions 
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.86,416.02,other,SI=N Exclusions 
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.40333,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions 
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.61749,416.02,other,SI=N Exclusions 
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.61749,416.02,other,SI=N Exclusions 
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.61749,416.02,other,SI=N Exclusions 
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions 
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15.61,,,15.61,14.7,4668.927562,fee schedule,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.03,416.02,other,SI=N Exclusions 
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.03,416.02,other,SI=N Exclusions 
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.03,416.02,other,SI=N Exclusions 
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.99,,,3.99,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.99,,,3.99,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.99,,,3.99,1.35,1059.84,fee schedule,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,4.51,,,4.51,0.46,416.02,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.51,,,4.51,0.46,416.02,fee schedule,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.63,416.02,other,SI=N Exclusions 
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.78,416.02,other,SI=N Exclusions 
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.78,416.02,other,SI=N Exclusions 
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26.96,,,26.96,24.19,6805.34016,fee schedule,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26.96,,,26.96,24.19,6805.34016,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1030,HCPCS,636,RC,00009-3073-03,NDC,outpatient,1,ML,22.62,15.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.07819,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-01,NDC,outpatient,1,ML,25.95,18.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.82353,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,00009-3475-03,NDC,outpatient,1,ML,34.96,24.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.82353,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-05,NDC,outpatient,1,ML,25.94,18.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.82353,416.02,other,SI=N Exclusions 
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.03,416.02,other,SI=N Exclusions 
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions 
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.295505,416.02,other,SI=N Exclusions 
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.295505,416.02,other,SI=N Exclusions 
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.295505,416.02,other,SI=N Exclusions 
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.29108,416.02,other,SI=N Exclusions 
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.29108,416.02,other,SI=N Exclusions 
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.29108,416.02,other,SI=N Exclusions 
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.28219,416.02,other,SI=N Exclusions 
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.28219,416.02,other,SI=N Exclusions 
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.28219,416.02,other,SI=N Exclusions 
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4888.1,,,4888.1,399.86,9367.9104,fee schedule,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-01,NDC,outpatient,10,ML,44.91,31.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00409-2634-25,NDC,outpatient,10,ML,71.61,50.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-03,NDC,outpatient,10,ML,44.91,31.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-06,NDC,outpatient,0.5,ML,12.4,8.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-11,NDC,outpatient,1,ML,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-01,NDC,outpatient,1,ML,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-96,NDC,outpatient,0.5,ML,12.4,8.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-03,NDC,outpatient,1,ML,11.43,8.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-31,NDC,outpatient,1,ML,11.43,8.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-25,NDC,outpatient,1,ML,11.17,7.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-01,NDC,outpatient,1,ML,11.17,7.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
CONC DILAUDID 10 MG/ML PCA,RX-4080160,CDM,J1170,HCPCS,636,RC,99999-0000-95,NDC,outpatient,50,ML,267.65,187.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions 
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,87.49,,,87.49,87.49,442.10688,fee schedule,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.3402,416.02,other,SI=N Exclusions 
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,715.9,,,715.9,399.86,1422.7584,fee schedule,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.763505,945.2928,other,SI=N Exclusions 
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.763505,945.2928,other,SI=N Exclusions 
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.763505,945.2928,other,SI=N Exclusions 
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.763505,945.2928,other,SI=N Exclusions 
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.78,416.02,other,SI=N Exclusions 
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.78,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,224.63,,,224.63,224.63,13826.65728,fee schedule,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.86,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions 
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65.38,,,65.38,52.988735,416.02,fee schedule,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65.38,,,65.38,52.988735,416.02,fee schedule,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,382.79,,,382.79,339.74932,1162.26048,fee schedule,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.1,,,1.1,1.1,1903.32672,fee schedule,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions 
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions 
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions 
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions 
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions 
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14.4,,,14.4,7.3781655,1590,fee schedule,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14.4,,,14.4,7.3781655,1590,fee schedule,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,1056.72192,other,SI=N Exclusions 
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,1056.72192,other,SI=N Exclusions 
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.85,,,49.85,48.47,416.02,fee schedule,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.85,,,49.85,48.47,416.02,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,82.19,,,82.19,77.77,1531.4,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,82.19,,,82.19,77.77,1531.4,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,82.19,,,82.19,77.77,1531.4,fee schedule,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49,,,49,44.12,1447.31904,fee schedule,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49,,,49,44.12,1447.31904,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,36.41,416.02,other,SI=N Exclusions 
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions 
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,192.3,,,192.3,90.641875,579.456,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,192.3,,,192.3,90.641875,579.456,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,192.3,,,192.3,90.641875,579.456,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,192.3,,,192.3,90.641875,579.456,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108.93,,,108.93,101.41,468.94848,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108.93,,,108.93,101.41,468.94848,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108.93,,,108.93,101.41,468.94848,fee schedule,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.28,416.02,other,SI=N Exclusions 
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.28,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,581.78,,,581.78,333.276985,1140.11904,fee schedule,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,581.78,,,581.78,333.276985,1140.11904,fee schedule,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.56878,416.02,other,SI=N Exclusions 
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.56878,416.02,other,SI=N Exclusions 
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.56878,416.02,other,SI=N Exclusions 
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.56878,416.02,other,SI=N Exclusions 
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,27.14,416.02,other,SI=N Exclusions 
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,347.15,,,347.15,85.36837,416.02,fee schedule,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32.22,,,32.22,32.22,2399.94624,fee schedule,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17.67,,,17.67,17.18,416.02,fee schedule,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17.67,,,17.67,17.18,416.02,fee schedule,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21,416.02,other,SI=N Exclusions 
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21,416.02,other,SI=N Exclusions 
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21,416.02,other,SI=N Exclusions 
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21,416.02,other,SI=N Exclusions 
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.83,416.02,other,SI=N Exclusions 
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.83,416.02,other,SI=N Exclusions 
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions 
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.19,,,0.19,0.19,416.02,fee schedule,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.19,,,0.19,0.19,416.02,fee schedule,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.36,416.02,fee schedule,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.36,,,0.36,0.36,416.02,fee schedule,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,794.16,,,794.16,114.43,1432.33536,fee schedule,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,794.16,,,794.16,114.43,1432.33536,fee schedule,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.18,,,1.18,1,1207.54176,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions 
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.63,,,1.63,1.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.63,,,1.63,1.24,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions 
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1617.65,,,1617.65,399.86,10964.15232,fee schedule,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1617.65,,,1617.65,399.86,10964.15232,fee schedule,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions 
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2001,HCPCS,636,RC,00338-0409-03,NDC,outpatient,500,ML,42.7,29.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions 
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.30786,416.02,other,SI=N Exclusions 
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.30786,416.02,other,SI=N Exclusions 
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30.44,,,30.44,29.75,6255.52128,fee schedule,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.18518,416.02,other,SI=N Exclusions 
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.18518,416.02,other,SI=N Exclusions 
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.18518,416.02,other,SI=N Exclusions 
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.18518,416.02,other,SI=N Exclusions 
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.52,,,1.52,1.07677,506.21952,fee schedule,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions 
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions 
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions 
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions 
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions 
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions 
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.18,,,0.18,0.18,416.02,fee schedule,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.18,,,0.18,0.18,416.02,fee schedule,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.41,416.02,other,SI=N Exclusions 
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.41,416.02,other,SI=N Exclusions 
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.41,416.02,other,SI=N Exclusions 
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.41,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.46,1022.48448,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.46,1022.48448,other,SI=N Exclusions 
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.46,1022.48448,other,SI=N Exclusions 
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.46,1022.48448,other,SI=N Exclusions 
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.72,416.02,other,SI=N Exclusions 
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.72,416.02,other,SI=N Exclusions 
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.41,,,1.41,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.41,,,1.41,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.41,,,1.41,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38.29,,,38.29,38.29,2935.67232,fee schedule,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38.29,,,38.29,38.29,2935.67232,fee schedule,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38.29,,,38.29,38.29,2935.67232,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.317135,416.02,other,SI=N Exclusions 
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.317135,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.54,416.02,other,SI=N Exclusions 
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.54,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.263845,416.02,other,SI=N Exclusions 
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.263845,416.02,other,SI=N Exclusions 
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions 
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.5,416.02,other,SI=N Exclusions 
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3482.15,,,3482.15,399.86,45671.09376,fee schedule,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.01,416.02,other,SI=N Exclusions 
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.01,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions 
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.739875,416.02,other,SI=N Exclusions 
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.739875,416.02,other,SI=N Exclusions 
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.89655,416.02,other,SI=N Exclusions 
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.89655,416.02,other,SI=N Exclusions 
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.89655,416.02,other,SI=N Exclusions 
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.89655,416.02,other,SI=N Exclusions 
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions 
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.42,,,5.42,5.42,416.02,fee schedule,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.42,,,5.42,5.42,416.02,fee schedule,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.40469,416.02,other,SI=N Exclusions 
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.586535,416.02,other,SI=N Exclusions 
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.586535,416.02,other,SI=N Exclusions 
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,546.07,,,546.07,5.484535,1082.90304,fee schedule,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,546.07,,,546.07,5.484535,1082.90304,fee schedule,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,546.07,,,546.07,5.484535,1082.90304,fee schedule,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,546.07,,,546.07,5.484535,1082.90304,fee schedule,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.43,416.02,other,SI=N Exclusions 
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.43,416.02,other,SI=N Exclusions 
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.95,416.02,other,SI=N Exclusions 
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.95,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions 
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,531.25,,,531.25,7.136465,1471.59552,fee schedule,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,531.25,,,531.25,7.136465,1471.59552,fee schedule,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,371.29,,,371.29,357.36,11800.75008,fee schedule,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,371.29,,,371.29,357.36,11800.75008,fee schedule,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.88,455.8464,other,SI=N Exclusions 
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.88,455.8464,other,SI=N Exclusions 
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.88,455.8464,other,SI=N Exclusions 
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34.34,,,34.34,33.71,3005.13792,fee schedule,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34.34,,,34.34,33.71,3005.13792,fee schedule,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.3,,,11.3,10.7,2359.38048,fee schedule,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.3,,,11.3,10.7,2359.38048,fee schedule,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.05,,,101.05,95.47,5307.61728,fee schedule,
ROMIPLOSTIM 125 MCG SC SOLR|DISCARDED DRUG NOT ADMINISTERED,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,101.05,,,101.05,95.47,5307.61728,fee schedule,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.05,,,101.05,95.47,5307.61728,fee schedule,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,157.07,,,157.07,139.22,12730.14528,fee schedule,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,157.07,,,157.07,139.22,12730.14528,fee schedule,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.12,416.02,other,SI=N Exclusions 
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.12,416.02,other,SI=N Exclusions 
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.12,416.02,other,SI=N Exclusions 
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.12,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-28,NDC,outpatient,1,UN,20.03,14.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.24,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-30,NDC,outpatient,1,UN,20.03,14.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.24,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2930,HCPCS,636,RC,00009-0698-01,NDC,outpatient,1,UN,79.04,55.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-22,NDC,outpatient,1,UN,31.87,22.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-25,NDC,outpatient,1,UN,31.87,22.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2930,HCPCS,636,RC,00009-0850-01,NDC,outpatient,1,UN,735.77,515.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2930,HCPCS,636,RC,00009-0758-01,NDC,outpatient,1,UN,87,60.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ ACT-O-VIAL,RX-4081056,CDM,J2930,HCPCS,636,RC,00009-0018-20,NDC,outpatient,1,UN,235.14,164.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ ACT-O-VIAL,RX-4081057,CDM,J2930,HCPCS,636,RC,00009-0003-02,NDC,outpatient,1,UN,180.85,126.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions 
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91.47,,,91.47,89.15,17236.24704,fee schedule,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91.47,,,91.47,89.15,17236.24704,fee schedule,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91.47,,,91.47,89.15,17236.24704,fee schedule,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91.47,,,91.47,89.15,17236.24704,fee schedule,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.57,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions 
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,157.72,,,157.72,152.7,14884.48512,fee schedule,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.358225,416.02,other,SI=N Exclusions 
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.358225,416.02,other,SI=N Exclusions 
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.358225,416.02,other,SI=N Exclusions 
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.358225,416.02,other,SI=N Exclusions 
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.63291,416.02,other,SI=N Exclusions 
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.63291,416.02,other,SI=N Exclusions 
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.63291,416.02,other,SI=N Exclusions 
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.63291,416.02,other,SI=N Exclusions 
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2073.34,,,2073.34,399.86,4191.12192,fee schedule,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52,416.02,other,SI=N Exclusions 
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,44.72489,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.96,,,5.96,5.91,5460.64128,fee schedule,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.96,,,5.96,5.91,5460.64128,fee schedule,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.96,,,5.96,5.91,5460.64128,fee schedule,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.9,416.02,other,SI=N Exclusions 
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.9,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions 
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions 
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22.26,,,22.26,22.26,18370.38336,fee schedule,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.41,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions 
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.528165,416.02,other,SI=N Exclusions 
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.528165,416.02,other,SI=N Exclusions 
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.15,416.02,other,SI=N Exclusions 
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.15,416.02,other,SI=N Exclusions 
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.15,416.02,other,SI=N Exclusions 
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.15,416.02,other,SI=N Exclusions 
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.69,,,5.69,5.69,1897.8816,fee schedule,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions 
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions 
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.36,416.02,other,SI=N Exclusions 
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.36,416.02,other,SI=N Exclusions 
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.36,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.51,416.02,other,SI=N Exclusions 
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.51,416.02,other,SI=N Exclusions 
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.43,416.02,other,SI=N Exclusions 
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.43,416.02,other,SI=N Exclusions 
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.47,416.02,other,SI=N Exclusions 
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.47,416.02,other,SI=N Exclusions 
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.47,416.02,other,SI=N Exclusions 
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10347.43296,other,SI=N Exclusions 
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.54,416.02,other,SI=N Exclusions 
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.54,416.02,other,SI=N Exclusions 
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.14,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.62,416.02,other,SI=N Exclusions 
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.23,416.02,other,SI=N Exclusions 
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.23,416.02,other,SI=N Exclusions 
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.39,416.02,other,SI=N Exclusions 
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.39,416.02,other,SI=N Exclusions 
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.39,416.02,other,SI=N Exclusions 
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.39,416.02,other,SI=N Exclusions 
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.89986,416.02,other,SI=N Exclusions 
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.4,,,3.4,2.568211,4642.0992,fee schedule,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.4,,,3.4,2.568211,4642.0992,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.28,,,1.28,1.26,2225.664,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.28,,,1.28,1.26,2225.664,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.55,,,1.55,1.25,2861.568,fee schedule,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.55,,,1.55,1.25,2861.568,fee schedule,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.85,,,3.85,3.35,3804.8256,fee schedule,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.85,,,3.85,3.35,3804.8256,fee schedule,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.34,,,2.34,1.94,10651.392,fee schedule,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,73.22,786.36288,other,SI=N Exclusions 
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.536555,416.02,other,SI=N Exclusions 
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.536555,416.02,other,SI=N Exclusions 
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.32,416.02,other,SI=N Exclusions 
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.52,,,0.52,0.52,416.02,fee schedule,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.52,,,0.52,0.52,416.02,fee schedule,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions 
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.66,,,76.66,69.53663,416.02,fee schedule,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.66,,,76.66,69.53663,416.02,fee schedule,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.72,0.370425,416.02,percent of total billed charges,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.96,0.370425,416.02,percent of total billed charges,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.42,0.370425,416.02,percent of total billed charges,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.73,0.370425,416.02,percent of total billed charges,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.73,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1.4,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.21,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,7.4,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.21,0.370425,416.02,percent of total billed charges,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1.68,0.370425,416.02,percent of total billed charges,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions 
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions 
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions 
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions 
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions 
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.2,,,7.2,7.2,2367.72096,fee schedule,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.2,,,7.2,7.2,2367.72096,fee schedule,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.32,416.02,other,SI=N Exclusions 
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.32,416.02,other,SI=N Exclusions 
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.43,,,5.43,5.43,2152.77312,fee schedule,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.43,,,5.43,5.43,2152.77312,fee schedule,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12.95,,,12.95,12.95,3900.27264,fee schedule,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72.7,,,72.7,72.7,7001.856,fee schedule,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72.7,,,72.7,72.7,7001.856,fee schedule,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.931495,416.02,other,SI=N Exclusions 
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.931495,416.02,other,SI=N Exclusions 
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.57,,,1.57,1.57,905.322979,fee schedule,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.57,,,1.57,1.57,905.322979,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,239.86,,,239.86,221.96,24824.61696,fee schedule,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,216.46,,,216.46,206.03,30463.31136,fee schedule,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.41,416.02,other,SI=N Exclusions 
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.41,416.02,other,SI=N Exclusions 
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.58,,,49.58,47.04,6870.26688,fee schedule,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75.48,,,75.48,72.08,3359.0784,fee schedule,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75.48,,,75.48,72.08,3359.0784,fee schedule,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.37,416.02,other,SI=N Exclusions 
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14.25,,,14.25,14.25,416.02,fee schedule,
CYCLOPHOSPHAMIDE 1 G IJ SOLR,RX-38270,CDM,J9070,HCPCS,636,RC,00781-3244-94,NDC,outpatient,1,UN,1602.63,1121.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.03,,,53.03,17.09,1230.81984,fee schedule,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9070,HCPCS,636,RC,00781-3233-94,NDC,outpatient,1,UN,1017.09,711.963,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.03,,,53.03,17.09,1230.81984,fee schedule,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9070,HCPCS,636,RC,10019-0957-01,NDC,outpatient,1,UN,1524.13,1066.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.03,,,53.03,17.09,1230.81984,fee schedule,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions 
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.69078,416.02,other,SI=N Exclusions 
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.69078,416.02,other,SI=N Exclusions 
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.18,,,4.18,4.18,1339.56096,fee schedule,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.18,,,4.18,4.18,1339.56096,fee schedule,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions 
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.34,416.02,other,SI=N Exclusions 
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,135.79,,,135.79,128.78,3097.0368,fee schedule,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions 
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,134.15,,,134.15,62.498555,604.75,fee schedule,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.83,416.02,other,SI=N Exclusions 
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.83,416.02,other,SI=N Exclusions 
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.83,416.02,other,SI=N Exclusions 
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.79,416.02,other,SI=N Exclusions 
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.79,416.02,other,SI=N Exclusions 
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.79,416.02,other,SI=N Exclusions 
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.79,416.02,other,SI=N Exclusions 
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,674.77,,,674.77,399.86,5828.5824,fee schedule,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,674.77,,,674.77,399.86,5828.5824,fee schedule,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,416.02,other,SI=N Exclusions 
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,416.02,other,SI=N Exclusions 
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,416.02,other,SI=N Exclusions 
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,134.06,,,134.06,122.55,12759.31392,fee schedule,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,134.06,,,134.06,122.55,12759.31392,fee schedule,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions 
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions 
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions 
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions 
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions 
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.67,416.02,other,SI=N Exclusions 
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.67,416.02,other,SI=N Exclusions 
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,27.33512,416.02,other,SI=N Exclusions 
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.51,,,176.51,165.86,17420.48256,fee schedule,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.51,,,176.51,165.86,17420.48256,fee schedule,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.51,,,176.51,165.86,17420.48256,fee schedule,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.51,,,176.51,165.86,17420.48256,fee schedule,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.88,,,176.88,167.93,74965.60128,fee schedule,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.88,,,176.88,167.93,74965.60128,fee schedule,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-37,NDC,outpatient,0.5,ML,3.4,2.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.27,416.02,other,SI=N Exclusions 
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-38,NDC,outpatient,0.5,ML,3.4,2.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.27,416.02,other,SI=N Exclusions 
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.47721,416.02,other,SI=N Exclusions 
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.47721,416.02,other,SI=N Exclusions 
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72.53,,,72.53,72.53,1721.82528,fee schedule,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions 
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.34,,,13.34,12.06,3366.45888,fee schedule,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions 
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2541.77,,,2541.77,399.86,4898.21952,fee schedule,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.22,,,58.22,54.81,12451.14624,fee schedule,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42.51,,,42.51,42.51,2565.35808,fee schedule,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42.51,,,42.51,42.51,2565.35808,fee schedule,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42.51,,,42.51,42.51,2565.35808,fee schedule,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42.51,,,42.51,42.51,2565.35808,fee schedule,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54.65,,,54.65,29.06,416.02,fee schedule,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31.75,,,31.75,30.46,16440.55296,fee schedule,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31.75,,,31.75,30.46,16440.55296,fee schedule,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31.75,,,31.75,30.46,16440.55296,fee schedule,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74.59,,,74.59,70.55,18103.04256,fee schedule,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,159.33,,,159.33,149.71,14042.8032,fee schedule,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,159.33,,,159.33,149.71,14042.8032,fee schedule,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.18,,,4.18,4.18,8613.9648,fee schedule,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.18,,,4.18,4.18,8613.9648,fee schedule,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16.12,,,16.12,15.37,14335.95648,fee schedule,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,373.77,,,373.77,356.51,15644.98176,fee schedule,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.07,,,71.07,68.87,15685.39392,fee schedule,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.07,,,71.07,68.87,15685.39392,fee schedule,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77.31,,,77.31,77.31,10318.18752,fee schedule,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77.31,,,77.31,77.31,10318.18752,fee schedule,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,398.13,,,398.13,223.44,900.08832,fee schedule,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32.21,,,32.21,32.21,4261.85472,fee schedule,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.5,416.02,other,SI=N Exclusions 
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40.45,,,40.45,38.33,13677.02016,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40.45,,,40.45,38.33,13677.02016,fee schedule,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77.94,,,77.94,77.94,3651.07968,fee schedule,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,77.94,,,77.94,77.94,3651.07968,fee schedule,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.95,416.02,other,SI=N Exclusions 
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.49,416.02,other,SI=N Exclusions 
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.49,416.02,other,SI=N Exclusions 
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.59,416.02,other,SI=N Exclusions 
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53,,,53,1.65,1060,fee schedule,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53,,,53,1.65,1060,fee schedule,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.37,,,29.37,4.41367,416.02,fee schedule,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.37,,,29.37,4.41367,416.02,fee schedule,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.37,,,29.37,4.41367,416.02,fee schedule,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.37,,,29.37,4.41367,416.02,fee schedule,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,878.46,,,878.46,110.03643,1222.676,fee schedule,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,878.46,,,878.46,110.03643,1222.676,fee schedule,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,878.46,,,878.46,110.03643,1222.676,fee schedule,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.76,,,101.76,23.579235,416.02,fee schedule,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.76,,,101.76,23.579235,416.02,fee schedule,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.76,,,101.76,23.579235,416.02,fee schedule,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.76,,,101.76,23.579235,416.02,fee schedule,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,62.26,16.49177,416.02,percent of total billed charges,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,62.26,16.49177,416.02,percent of total billed charges,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,62.26,16.49177,416.02,percent of total billed charges,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,262.88,,,262.88,31.76675,416.02,fee schedule,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,262.88,,,262.88,31.76675,416.02,fee schedule,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,262.88,,,262.88,31.76675,416.02,fee schedule,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,262.88,,,262.88,31.76675,416.02,fee schedule,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.68,,,337.68,335.72,5377.9968,fee schedule,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,57.87,15.326615,416.02,percent of total billed charges,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,78.54,15.326615,416.02,percent of total billed charges,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,78.54,15.326615,416.02,percent of total billed charges,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.51,,,56.51,17.225885,416.02,fee schedule,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.51,,,56.51,17.225885,416.02,fee schedule,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.51,,,56.51,17.225885,416.02,fee schedule,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,228.45,50.613525,568.638,percent of total billed charges,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,228.45,50.613525,568.638,percent of total billed charges,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,223.65,50.613525,568.638,percent of total billed charges,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,223.65,50.613525,568.638,percent of total billed charges,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,191.09,50.613525,568.638,percent of total billed charges,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,232.75,50.613525,568.638,percent of total billed charges,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,211.68,50.613525,568.638,percent of total billed charges,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,198.62,50.613525,568.638,percent of total billed charges,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.95,,,23.95,20.61,416.02,fee schedule,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,364.01,52.37136,418.655068,percent of total billed charges,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,418.66,52.37136,418.655068,percent of total billed charges,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,364.01,52.37136,418.655068,percent of total billed charges,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,364.01,52.37136,418.655068,percent of total billed charges,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,197.73,52.37136,418.655068,percent of total billed charges,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,126.4,,,126.4,125.65,1058.40384,fee schedule,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,126.4,,,126.4,125.65,1058.40384,fee schedule,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3409.78176,other,SI=N Exclusions 
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,252.25,3748.3008,other,SI=N Exclusions 
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,252.25,3748.3008,other,SI=N Exclusions 
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.737705,686.06,other,SI=N Exclusions 
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions 
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3534.81216,other,SI=N Exclusions 
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3534.81216,other,SI=N Exclusions 
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,394.43,,,394.43,326.6475,1117.44,fee schedule,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.49,,,56.49,49.4,942.336,fee schedule,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,211.31,,,211.31,123.6995,423.168,fee schedule,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.8,,,81.8,71.53,416.02,fee schedule,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,160.24,,,160.24,105.7395,416.02,fee schedule,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,871.33,163,871.3328,percent of total billed charges,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,172.26,,,172.26,136.61,1072.896,fee schedule,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1384.13,163,1384.1308,percent of total billed charges,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,556.11,,,556.11,163,1119.53,fee schedule,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,714.64,,,714.64,163,1476.21,fee schedule,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2191.89,163,2191.8936,percent of total billed charges,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,292.27,,,292.27,142.782,598.2,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,925.16,,,925.16,163,1698,fee schedule,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1747.75,163,1747.7512,percent of total billed charges,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1046.79,163,1046.786,percent of total billed charges,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,87.67,,,87.67,49.839,416.02,fee schedule,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,714.64,,,714.64,163,1265.41,fee schedule,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.16,,,29.16,19.9805,416.02,fee schedule,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.34,,,0.34,0.34,726.30528,fee schedule,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions 
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,416.02,other,SI=N Exclusions 
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,416.02,other,SI=N Exclusions 
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions 
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.85,,,2.85,2.55,416.02,fee schedule,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.85,,,2.85,2.55,416.02,fee schedule,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.85,,,2.85,2.55,416.02,fee schedule,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.85,,,2.85,2.55,416.02,fee schedule,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,133.08,,,133.08,87.98,1653.428703,fee schedule,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,133.08,,,133.08,87.98,1653.428703,fee schedule,
HC Telehealth Originating Site Facility Fee,PX-78000001,CDM,Q3014,HCPCS,983,RC,,,outpatient,,,373,261.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,316.15,83.7385,416.02,percent of total billed charges,
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,348.861775,3862.93248,other,SI=N Exclusions 
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,348.861775,3862.93248,other,SI=N Exclusions 
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,348.861775,3862.93248,other,SI=N Exclusions 
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,348.861775,3862.93248,other,SI=N Exclusions 
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,30.42,6716.16,other,SI=N Exclusions 
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.25,659.42016,other,SI=N Exclusions 
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.25,659.42016,other,SI=N Exclusions 
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.96,24594.91584,other,SI=N Exclusions 
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.96,24594.91584,other,SI=N Exclusions 
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.96,24594.91584,other,SI=N Exclusions 
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions 
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions 
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions 
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions 
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions 
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions 
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions 
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions 
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions 
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions 
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions 
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions 
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,8051.0208,other,SI=N Exclusions 
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,8051.0208,other,SI=N Exclusions 
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,8051.0208,other,SI=N Exclusions 
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,46.98,6518.784,other,SI=N Exclusions 
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.16,4034.304,other,SI=N Exclusions 
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.16,4034.304,other,SI=N Exclusions 
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions 
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions 
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions 
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions 
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions 
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions 
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions 
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions 
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions 
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions 
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions 
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions 
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions 
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions 
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions 
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions 
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions 
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions 
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.4745,3643.99872,other,SI=N Exclusions 
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.4745,3643.99872,other,SI=N Exclusions 
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.4745,3643.99872,other,SI=N Exclusions 
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.4745,3643.99872,other,SI=N Exclusions 
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,102.28,3422.3616,other,SI=N Exclusions 
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,102.28,3422.3616,other,SI=N Exclusions 
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.62,,,13.62,13.62,1653.428703,fee schedule,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27.18,,,27.18,27.18,1653.428703,fee schedule,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27.18,,,27.18,27.18,1653.428703,fee schedule,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33.59,,,33.59,33.59,7269.974281,fee schedule,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33.59,,,33.59,33.59,7269.974281,fee schedule,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21.29,,,21.29,21.29,1590.89664,fee schedule,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.92,438.4896,other,SI=N Exclusions 
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.92,438.4896,other,SI=N Exclusions 
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions 
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.56,416.02,other,SI=N Exclusions 
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.56,416.02,other,SI=N Exclusions 
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.38,416.02,other,SI=N Exclusions 
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.38,416.02,other,SI=N Exclusions 
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.38,416.02,other,SI=N Exclusions 
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.38,416.02,other,SI=N Exclusions 
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions 
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.65,,,10.65,9.53,2181.7344,fee schedule,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.65,,,10.65,9.53,2181.7344,fee schedule,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-00,NDC,outpatient,650,ME,11.57,8.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-20,NDC,outpatient,650,ME,11.57,8.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-21,NDC,outpatient,650,ME,11.57,8.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-30,NDC,outpatient,650,ME,11.57,8.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,99999-0004-18,NDC,outpatient,2.5,ML,4.86,3.402,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,70954-0316-10,NDC,outpatient,50,ML,117.71,82.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,00904-7193-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,63739-0645-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,62332-0001-31,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FELBAMATE 600 MG ORAL TABS,RX-10025,CDM,S5000,HCPCS,259,RC,72578-0057-16,NDC,outpatient,1,UN,5.99,4.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-61,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-06,NDC,outpatient,1,UN,1.66,1.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-01,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-11,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-11,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,00054-0011-21,NDC,outpatient,1,UN,2.98,2.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-15,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-11,NDC,outpatient,1,UN,3.66,2.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,00054-0010-20,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-15,NDC,outpatient,1,UN,3.66,2.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-11,NDC,outpatient,1,UN,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,00904-6500-61,NDC,outpatient,1,UN,4.03,2.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-01,NDC,outpatient,1,UN,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUCONAZOLE 200 MG ORAL TABS,RX-10045,CDM,S5000,HCPCS,259,RC,00904-6501-61,NDC,outpatient,1,UN,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,64380-0737-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-11,NDC,outpatient,1,UN,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-15,NDC,outpatient,1,UN,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUCYTOSINE 500 MG ORAL CAPS,RX-10052,CDM,S5000,HCPCS,259,RC,42794-0010-08,NDC,outpatient,1,UN,233.01,163.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,00115-7033-01,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-11,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-15,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,16729-0542-35,NDC,outpatient,40,GR,458.18,320.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,51672-4118-06,NDC,outpatient,40,GR,108.41,75.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOXETINE HCL 10 MG ORAL CAPS,RX-10069,CDM,S5000,HCPCS,259,RC,16714-0720-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOXETINE HCL 20 MG ORAL CAPS,RX-10070,CDM,S5000,HCPCS,259,RC,00904-7346-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLURBIPROFEN SODIUM 0.03 % OP SOLN,RX-10080,CDM,S5000,HCPCS,259,RC,69292-0722-25,NDC,outpatient,2.5,ML,140.89,98.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUVOXAMINE MALEATE 50 MG ORAL TABS,RX-10085,CDM,S5000,HCPCS,259,RC,60505-0165-01,NDC,outpatient,1,UN,1.63,1.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOSINOPRIL SODIUM 10 MG ORAL TABS,RX-10094,CDM,S5000,HCPCS,259,RC,69097-0856-05,NDC,outpatient,1,UN,1.76,1.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RITONAVIR 100 MG ORAL TABS,RX-100995,CDM,S5000,HCPCS,259,RC,00074-2340-30,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,60505-0141-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,00904-6637-61,NDC,outpatient,1,UN,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLYBURIDE 2.5 MG ORAL TABS,RX-10126,CDM,S5000,HCPCS,259,RC,00093-8343-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLYCOPYRROLATE 1 MG ORAL TABS,RX-10130,CDM,S5000,HCPCS,259,RC,23155-0606-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-59,NDC,outpatient,1,UN,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-62,NDC,outpatient,1,UN,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 500 MG ORAL TABS,RX-102,CDM,S5000,HCPCS,259,RC,00904-6730-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,59762-0073-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,64380-0970-25,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-11,NDC,outpatient,60,ML,88.11,61.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-07,NDC,outpatient,60,ML,88.11,61.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE MICRONIZED POWD,RX-10217,CDM,S5000,HCPCS,259,RC,51552-0020-05,NDC,outpatient,100,GR,1580.42,1106.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,00904-7046-61,NDC,outpatient,1,UN,3.27,2.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-01,NDC,outpatient,1,UN,4.87,3.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-11,NDC,outpatient,1,UN,4.87,3.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-01,NDC,outpatient,1,UN,3.02,2.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-11,NDC,outpatient,1,UN,3.02,2.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-61,NDC,outpatient,5,ML,2.54,1.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-05,NDC,outpatient,5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-00,NDC,outpatient,5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,51672-2130-08,NDC,outpatient,120,ML,11.22,7.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-47,NDC,outpatient,473,ML,67.36,47.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-59,NDC,outpatient,5,ML,2.54,1.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,99999-0004-24,NDC,outpatient,5,ML,1.37,0.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-05,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-62,NDC,outpatient,5,ML,2.59,1.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-05,NDC,outpatient,5,ML,1398.02,978.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-00,NDC,outpatient,5,ML,1398.02,978.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-02,NDC,outpatient,1,UN,501.97,351.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-01,NDC,outpatient,1,UN,501.97,351.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDOMETHACIN SODIUM 1 MG IV SOLR,RX-10267,CDM,S5000,HCPCS,250,RC,63323-0659-03,NDC,outpatient,1,UN,1192.43,834.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,S5000,HCPCS,259,RC,00002-8315-01,NDC,outpatient,10,ML,61.5,43.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,S5000,HCPCS,259,RC,00002-8215-01,NDC,outpatient,10,ML,61.5,43.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,S5000,HCPCS,259,RC,45802-0732-30,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00713-0326-15,NDC,outpatient,15,GR,50.4,35.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00472-0370-15,NDC,outpatient,15,GR,93.12,65.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,S5000,HCPCS,259,RC,00168-0041-60,NDC,outpatient,60,ML,267,186.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOSORBIDE MONONITRATE 20 MG ORAL TABS,RX-10357,CDM,S5000,HCPCS,259,RC,00228-2620-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISRADIPINE 5 MG ORAL CAPS,RX-10363,CDM,S5000,HCPCS,259,RC,16252-0540-01,NDC,outpatient,1,UN,8.59,6.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ITRACONAZOLE 100 MG ORAL CAPS,RX-10364,CDM,S5000,HCPCS,259,RC,16714-0743-02,NDC,outpatient,1,UN,5.65,3.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,S5000,HCPCS,259,RC,00168-0099-15,NDC,outpatient,15,GR,22.57,15.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,00093-0314-01,NDC,outpatient,1,UN,4.33,3.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,70710-1710-01,NDC,outpatient,1,UN,3.63,2.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-01,NDC,outpatient,1,UN,1.32,0.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-11,NDC,outpatient,1,UN,1.32,0.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-01,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-11,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,16864-0000-18,NDC,outpatient,225,GR,41.06,28.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,30781-7098-79,NDC,outpatient,225,GR,41.06,28.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,00904-5984-26,NDC,outpatient,226,GR,13.08,9.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,51672-1300-05,NDC,outpatient,225,GR,61.08,42.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,63044-0484-09,NDC,outpatient,225,GR,29.04,20.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-01,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,72603-0115-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-11,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,57237-0014-01,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,63739-0567-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-02,NDC,outpatient,1,UN,2.7,1.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-04,NDC,outpatient,1,UN,1.99,1.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-20,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-01,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-11,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-01,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,69238-1835-01,NDC,outpatient,1,UN,1.64,1.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-01,NDC,outpatient,1,UN,2.79,1.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-20,NDC,outpatient,1,UN,2.79,1.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00527-3287-46,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00378-1823-77,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00074-3727-90,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-01,NDC,outpatient,1,UN,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-20,NDC,outpatient,1,UN,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-25,NDC,outpatient,5,ML,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-16,NDC,outpatient,30,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-02,NDC,outpatient,5,ML,4.55,3.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0163-30,NDC,outpatient,30,ML,6.17,4.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-27,NDC,outpatient,2,ML,4.85,3.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-01,NDC,outpatient,5,ML,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-26,NDC,outpatient,5,ML,4.55,3.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0159-74,NDC,outpatient,5,ML,3.68,2.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-12,NDC,outpatient,5,ML,4.55,3.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-97,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-02,NDC,outpatient,30,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-04,NDC,outpatient,2,ML,4.85,3.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-08,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-09,NDC,outpatient,5,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-57,NDC,outpatient,5,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-05,NDC,outpatient,5,ML,11.34,7.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-25,NDC,outpatient,2,ML,4.57,3.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0164-02,NDC,outpatient,2,ML,4.16,2.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-07,NDC,outpatient,5,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-09,NDC,outpatient,2,ML,8.69,6.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-25,NDC,outpatient,5,ML,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-01,NDC,outpatient,2,ML,4.57,3.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-04,NDC,outpatient,5,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-97,NDC,outpatient,10,ML,28.48,19.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-11,NDC,outpatient,2,ML,4.57,3.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-12,NDC,outpatient,10,ML,10.34,7.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0165-05,NDC,outpatient,5,ML,4.63,3.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-01,NDC,outpatient,5,ML,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-10,NDC,outpatient,5,ML,11.34,7.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-02,NDC,outpatient,10,ML,10.34,7.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-27,NDC,outpatient,2,ML,8.69,6.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-03,NDC,outpatient,10,ML,28.48,19.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-57,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-16,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-16,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-17,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-03,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-02,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-17,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-27,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-07,NDC,outpatient,30,ML,30.31,21.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-37,NDC,outpatient,30,ML,30.31,21.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-01,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-89,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-03,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-11,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-27,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-01,NDC,outpatient,20,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-02,NDC,outpatient,20,ML,30.18,21.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-17,NDC,outpatient,10,ML,19.13,13.391,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-27,NDC,outpatient,20,ML,30.18,21.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-11,NDC,outpatient,20,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-01,NDC,outpatient,1,UN,2.51,1.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-89,NDC,outpatient,1,UN,2.51,1.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN,RX-10442,CDM,S5000,HCPCS,250,RC,39822-0151-01,NDC,outpatient,1,ML,1739.29,1217.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,68382-0582-01,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,00093-2179-01,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,00904-6798-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-03,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LISINOPRIL 5 MG ORAL TABS,RX-10451,CDM,S5000,HCPCS,259,RC,00904-6797-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-01,NDC,outpatient,1,UN,1.52,1.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-11,NDC,outpatient,1,UN,1.52,1.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68462-0224-01,NDC,outpatient,1,UN,1,0.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-11,NDC,outpatient,1,UN,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-01,NDC,outpatient,1,UN,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-11,NDC,outpatient,1,UN,11.87,8.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-13,NDC,outpatient,1,UN,11.87,8.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,62559-0265-30,NDC,outpatient,1,UN,10.97,7.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,69918-0301-30,NDC,outpatient,1,UN,6.2,4.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-03,NDC,outpatient,1,UN,223.91,156.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-02,NDC,outpatient,1,UN,223.91,156.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,00904-6852-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,68382-0520-01,NDC,outpatient,1,UN,18.05,12.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,59762-1001-01,NDC,outpatient,1,UN,20.25,14.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAFENIDE ACETATE 85 MG/GM EX CREA,RX-10478,CDM,S5000,HCPCS,259,RC,16571-0723-60,NDC,outpatient,56.7,GR,282.85,197.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,25021-0602-03,NDC,outpatient,3,ML,26.44,18.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-03,NDC,outpatient,3,ML,31.83,22.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,51754-0501-03,NDC,outpatient,3,ML,27.32,19.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-01,NDC,outpatient,3,ML,31.83,22.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM OXIDE 140 MG ORAL CAPS,RX-10490,CDM,S5000,HCPCS,259,RC,60569-0495-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-30,NDC,outpatient,1,UN,1.95,1.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-33,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-03,NDC,outpatient,946,ML,46.31,32.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-05,NDC,outpatient,15,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-13,NDC,outpatient,946,ML,46.31,32.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-04,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE ER 250 MG ORAL CPCR,RX-10533,CDM,S5000,HCPCS,259,RC,54092-0189-81,NDC,outpatient,1,UN,12.49,8.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BROMOCRIPTINE MESYLATE 0.8 MG ORAL TABS,RX-105409,CDM,S5000,HCPCS,259,RC,68012-0258-20,NDC,outpatient,1,UN,23.23,16.261,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,00904-7162-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,00131-5410-72,NDC,outpatient,5,ML,47,32.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,99999-0001-42,NDC,outpatient,20,ML,187.97,131.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-11,NDC,outpatient,1,UN,7.92,5.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-21,NDC,outpatient,1,UN,7.92,5.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,23155-0070-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-01,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-11,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-10,NDC,outpatient,10,ML,17.38,12.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-71,NDC,outpatient,30,ML,36.85,25.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-11,NDC,outpatient,10,ML,18.15,12.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-02,NDC,outpatient,30,ML,28.84,20.188,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-01,NDC,outpatient,10,ML,18.15,12.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-30,NDC,outpatient,30,ML,36.85,25.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-70,NDC,outpatient,10,ML,17.38,12.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-01,NDC,outpatient,10,ML,18.16,12.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-37,NDC,outpatient,30,ML,28.84,20.188,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-17,NDC,outpatient,10,ML,18.16,12.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-31,NDC,outpatient,30,ML,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-37,NDC,outpatient,30,ML,30.98,21.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-11,NDC,outpatient,10,ML,11.21,7.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-16,NDC,outpatient,30,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-01,NDC,outpatient,30,ML,30.98,21.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-02,NDC,outpatient,30,ML,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-04,NDC,outpatient,10,ML,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-01,NDC,outpatient,10,ML,11.21,7.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-17,NDC,outpatient,30,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-17,NDC,outpatient,10,ML,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-02,NDC,outpatient,1,UN,78.51,54.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-94,NDC,outpatient,1,UN,190.6,133.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-08,NDC,outpatient,1,UN,71.96,50.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-11,NDC,outpatient,1,UN,190.6,133.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-20,NDC,outpatient,1,UN,11.25,7.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-01,NDC,outpatient,1,UN,11.25,7.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-01,NDC,outpatient,1,UN,12.79,8.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-20,NDC,outpatient,1,UN,12.79,8.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,S5000,HCPCS,259,RC,16714-0557-01,NDC,outpatient,70,GR,66.67,46.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,62559-0820-01,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,00093-8739-01,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,50742-0239-01,NDC,outpatient,1,UN,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEXILETINE HCL 200 MG ORAL CAPS,RX-10596,CDM,S5000,HCPCS,259,RC,00093-8740-01,NDC,outpatient,1,UN,3.1,2.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,11701-0038-16,NDC,outpatient,85,GR,25.73,18.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,53329-0169-79,NDC,outpatient,85,GR,16.27,11.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MICROFIBRILLAR COLL HEMOSTAT EX PADS,RX-10605,CDM,S5000,HCPCS,259,RC,53276-1010-08,NDC,outpatient,1,UN,496.85,347.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,S5000,HCPCS,250,RC,53276-1010-02,NDC,outpatient,1,GR,993.69,695.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ULIPRISTAL ACETATE 30 MG ORAL TABS,RX-106079,CDM,S5000,HCPCS,259,RC,73302-0456-01,NDC,outpatient,1,UN,159.36,111.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00245-0211-11,NDC,outpatient,1,UN,1.99,1.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00378-1901-01,NDC,outpatient,1,UN,2.12,1.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-20,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,63739-0145-10,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-01,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00904-6818-61,NDC,outpatient,1,UN,2.24,1.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-89,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-01,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-106248,CDM,S5000,HCPCS,259,RC,24208-0830-60,NDC,outpatient,5,ML,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-106249,CDM,S5000,HCPCS,259,RC,61314-0631-36,NDC,outpatient,3.5,GR,69.78,48.846,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-01,NDC,outpatient,1,UN,9.27,6.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,00025-1451-34,NDC,outpatient,1,UN,17.24,12.068,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,59762-5007-01,NDC,outpatient,1,UN,2.08,1.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-11,NDC,outpatient,1,UN,9.27,6.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-11,NDC,outpatient,1,UN,7.19,5.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-01,NDC,outpatient,1,UN,7.19,5.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-16,NDC,outpatient,50,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-01,NDC,outpatient,50,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-56,NDC,outpatient,1,UN,12.92,9.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-61,NDC,outpatient,1,UN,12.92,9.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-82,NDC,outpatient,1,UN,12.92,9.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-55,NDC,outpatient,1,UN,12.92,9.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,00406-8003-30,NDC,outpatient,0.25,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,99999-0002-18,NDC,outpatient,1,ML,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,68462-0180-22,NDC,outpatient,22,GR,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,45802-0112-22,NDC,outpatient,22,GR,13.61,9.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,51672-1312-00,NDC,outpatient,22,GR,11.07,7.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,00591-3670-01,NDC,outpatient,1,UN,1.2,0.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-11,NDC,outpatient,1,UN,3.85,2.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-21,NDC,outpatient,1,UN,3.85,2.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00904-7036-04,NDC,outpatient,1,UN,7.95,5.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-21,NDC,outpatient,1,UN,8.68,6.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-11,NDC,outpatient,1,UN,8.68,6.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00406-1170-03,NDC,outpatient,1,UN,4.49,3.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,62559-0205-90,NDC,outpatient,1,UN,35.49,24.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,68462-0120-90,NDC,outpatient,1,UN,18.98,13.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,68462-0121-90,NDC,outpatient,1,UN,27.58,19.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,42806-0502-09,NDC,outpatient,1,UN,24.73,17.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-1362-23,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-3029-23,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00536-1372-23,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00135-0242-08,NDC,outpatient,1,UN,2.37,1.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-00,NDC,outpatient,1,UN,5.11,3.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-11,NDC,outpatient,1,UN,5.11,3.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,00904-7137-61,NDC,outpatient,1,UN,6.96,4.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-15,NDC,outpatient,1,UN,7.34,5.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,16714-0439-01,NDC,outpatient,1,UN,7.17,5.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-01,NDC,outpatient,1,UN,9.67,6.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-11,NDC,outpatient,1,UN,9.67,6.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-11,NDC,outpatient,1,UN,7.34,5.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,42858-0750-40,NDC,outpatient,1,UN,220.77,154.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-01,NDC,outpatient,1,UN,146.92,102.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-04,NDC,outpatient,1,UN,146.92,102.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-40,NDC,outpatient,1,UN,232.52,162.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-21,NDC,outpatient,1,UN,232.52,162.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLSALAZINE SODIUM 250 MG ORAL CAPS,RX-10773,CDM,S5000,HCPCS,259,RC,00037-6860-10,NDC,outpatient,1,UN,61.39,42.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-05,NDC,outpatient,5,ML,7.15,5.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-40,NDC,outpatient,5,ML,7.15,5.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,99999-0001-41,NDC,outpatient,5,ML,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-00,NDC,outpatient,5,ML,4.92,3.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISACODYL 5 MG ORAL TBEC,RX-1079,CDM,S5000,HCPCS,259,RC,00904-6407-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-12,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,81421-0021-03,NDC,outpatient,1,UN,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-50,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-50,NDC,outpatient,1,UN,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-02,NDC,outpatient,2.5,GR,13.58,9.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-01,NDC,outpatient,2.5,GR,13.58,9.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-30,NDC,outpatient,5,GR,13.67,9.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-26,NDC,outpatient,5,GR,13.67,9.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,00406-8557-30,NDC,outpatient,30,ML,133.24,93.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,99999-0002-27,NDC,outpatient,1,ML,7.21,5.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-05,NDC,outpatient,5,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-55,NDC,outpatient,5,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-23,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,42858-0001-10,NDC,outpatient,1,UN,1,0.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-62,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,10702-0018-50,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-11,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00904-6966-61,NDC,outpatient,1,UN,1.01,0.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAROXETINE HCL 20 MG ORAL TABS,RX-10855,CDM,S5000,HCPCS,259,RC,63739-0963-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISMUTH SUBCARBONATE POWD,RX-1086,CDM,S5000,HCPCS,259,RC,62991-2844-02,NDC,outpatient,100,GR,276.06,193.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,99999-0001-91,NDC,outpatient,30,ML,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,37000-0475-08,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PERMETHRIN 5 % EX CREA,RX-10917,CDM,S5000,HCPCS,259,RC,00472-0242-60,NDC,outpatient,60,GR,76.37,53.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00378-1905-77,NDC,outpatient,1,UN,17.44,12.208,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,42571-0259-30,NDC,outpatient,1,UN,4.47,3.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-11,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,31722-0623-90,NDC,outpatient,1,UN,7.15,5.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-21,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00310-0095-30,NDC,outpatient,1,UN,54.75,38.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOXYBENZAMINE HCL 10 MG ORAL CAPS,RX-10945,CDM,S5000,HCPCS,259,RC,66993-0066-02,NDC,outpatient,1,UN,73.53,51.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-01,NDC,outpatient,1,UN,1208.89,846.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-10,NDC,outpatient,1,UN,1233.54,863.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LINAGLIPTIN 5 MG ORAL TABS,RX-109773,CDM,S5000,HCPCS,259,RC,00597-0140-61,NDC,outpatient,1,UN,56.14,39.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RILPIVIRINE HCL 25 MG ORAL TABS,RX-109909,CDM,S5000,HCPCS,259,RC,59676-0278-01,NDC,outpatient,1,UN,209.04,146.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-25,NDC,outpatient,1,UN,4.05,2.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-95,NDC,outpatient,1,UN,4.05,2.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,00904-7199-07,NDC,outpatient,1,UN,3.73,2.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYTOIN SODIUM EXTENDED 30 MG ORAL CAPS,RX-11019,CDM,S5000,HCPCS,259,RC,00071-3740-66,NDC,outpatient,1,UN,5.97,4.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-94,NDC,outpatient,1,UN,227.6,159.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-11,NDC,outpatient,1,UN,227.6,159.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FIDAXOMICIN 200 MG ORAL TABS,RX-110360,CDM,S5000,HCPCS,259,RC,52015-0080-01,NDC,outpatient,1,UN,501.77,351.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TICAGRELOR 90 MG ORAL TABS,RX-110427,CDM,S5000,HCPCS,259,RC,00186-0777-39,NDC,outpatient,1,UN,30.77,21.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00904-2500-91,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00536-4306-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLYSACCHARIDE IRON COMPLEX 150 MG ORAL CAPS,RX-11050,CDM,S5000,HCPCS,259,RC,00904-5395-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,00178-0610-01,NDC,outpatient,1,UN,7.92,5.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-32,NDC,outpatient,1,UN,8.47,5.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-33,NDC,outpatient,1,UN,8.47,5.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,27241-0139-09,NDC,outpatient,60,ML,35.52,24.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,68180-0678-01,NDC,outpatient,60,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,00004-0822-05,NDC,outpatient,60,ML,624.52,437.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,99999-0000-41,NDC,outpatient,5,ML,52.63,36.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAVASTATIN SODIUM 10 MG ORAL TABS,RX-11110,CDM,S5000,HCPCS,259,RC,00904-5891-61,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,00904-5892-61,NDC,outpatient,1,UN,2.3,1.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-01,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-20,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-11,NDC,outpatient,1,UN,2.64,1.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-01,NDC,outpatient,1,UN,2.64,1.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,S5000,HCPCS,259,RC,00574-7226-12,NDC,outpatient,1,UN,26.18,18.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-12,NDC,outpatient,1,UN,43.38,30.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-06,NDC,outpatient,1,UN,43.38,30.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,S5000,HCPCS,259,RC,00713-0526-12,NDC,outpatient,1,UN,43.38,30.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPAFENONE HCL 150 MG ORAL TABS,RX-11146,CDM,S5000,HCPCS,259,RC,00591-0582-01,NDC,outpatient,1,UN,1.95,1.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPAFENONE HCL 225 MG ORAL TABS,RX-11147,CDM,S5000,HCPCS,259,RC,00591-0583-01,NDC,outpatient,1,UN,1.32,0.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,00904-6622-61,NDC,outpatient,1,UN,3.64,2.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,68382-0659-06,NDC,outpatient,1,UN,1.59,1.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOSTIGMINE BROMIDE ER 180 MG ORAL TBCR,RX-11240,CDM,S5000,HCPCS,259,RC,47781-0335-30,NDC,outpatient,1,UN,71.76,50.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIMETHAMINE 25 MG ORAL TABS,RX-11246,CDM,S5000,HCPCS,259,RC,43598-0672-01,NDC,outpatient,1,UN,1019.51,713.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-00,NDC,outpatient,2,ML,92.93,65.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-05,NDC,outpatient,2,ML,92.93,65.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RAMIPRIL 1.25 MG ORAL CAPS,RX-11258,CDM,S5000,HCPCS,259,RC,68382-0144-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,57237-0224-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,68382-0146-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-11,NDC,outpatient,1,UN,9.33,6.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-21,NDC,outpatient,1,UN,9.33,6.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,68180-0157-01,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIBAVIRIN 200 MG ORAL CAPS,RX-11286,CDM,S5000,HCPCS,259,RC,65862-0290-84,NDC,outpatient,1,UN,5.94,4.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFABUTIN 150 MG ORAL CAPS,RX-11290,CDM,S5000,HCPCS,259,RC,59762-1350-01,NDC,outpatient,1,UN,47.58,33.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,67457-0445-60,NDC,outpatient,1,UN,242,169.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,00068-0597-01,NDC,outpatient,1,UN,360.5,252.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,63323-0351-20,NDC,outpatient,1,UN,246.71,172.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-11,NDC,outpatient,1,UN,10.17,7.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-21,NDC,outpatient,1,UN,10.17,7.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-01,NDC,outpatient,1,UN,6.25,4.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-11,NDC,outpatient,1,UN,6.25,4.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-01,NDC,outpatient,1,UN,9.15,6.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-11,NDC,outpatient,1,UN,9.15,6.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-113082,CDM,S5000,HCPCS,259,RC,00487-5901-99,NDC,outpatient,1,UN,5.79,4.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,65628-0070-03,NDC,outpatient,5,ML,27.75,19.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,99999-9003-64,NDC,outpatient,5,ML,27.75,19.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,76282-0213-18,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-04,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-01,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-11,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,00904-6925-61,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,68180-0352-09,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,16729-0346-10,NDC,outpatient,1,UN,5,3.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,67877-0638-30,NDC,outpatient,1,UN,1.86,1.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,63402-0302-30,NDC,outpatient,1,UN,165.29,115.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,S5000,HCPCS,259,RC,12870-0001-01,NDC,outpatient,10,UN,28.31,19.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-30,NDC,outpatient,30,ML,19.63,13.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-00,NDC,outpatient,30,ML,19.63,13.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-03,NDC,outpatient,500,ML,11.87,8.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-04,NDC,outpatient,1000,ML,15.82,11.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,S5000,HCPCS,259,RC,24208-0276-15,NDC,outpatient,15,ML,65.35,45.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-01,NDC,outpatient,1,UN,4.36,3.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-11,NDC,outpatient,1,UN,4.36,3.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-01,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-20,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,29033-0003-05,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,00093-2210-01,NDC,outpatient,1,UN,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,59762-0401-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,62135-0436-90,NDC,outpatient,1,UN,16.45,11.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,00527-1318-01,NDC,outpatient,1,UN,19.38,13.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,62559-0721-01,NDC,outpatient,1,UN,4.45,3.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-01,NDC,outpatient,2,ML,164.48,115.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-10,NDC,outpatient,2,ML,164.48,115.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-22,NDC,outpatient,1,UN,883.55,618.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-21,NDC,outpatient,1,UN,883.55,618.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,S5000,HCPCS,250,RC,60793-0215-05,NDC,outpatient,1,UN,195.76,137.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,60758-0802-05,NDC,outpatient,5,ML,11.17,7.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,64980-0513-05,NDC,outpatient,5,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,60758-0801-05,NDC,outpatient,5,ML,22.48,15.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,64980-0514-05,NDC,outpatient,5,ML,21.94,15.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,S5000,HCPCS,259,RC,00078-0876-01,NDC,outpatient,3.5,GR,1115.32,780.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,S5000,HCPCS,259,RC,24208-0295-25,NDC,outpatient,2.5,ML,173.64,121.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,66993-0831-02,NDC,outpatient,1,UN,36.58,25.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,59212-0002-01,NDC,outpatient,1,UN,60.49,42.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,S5000,HCPCS,259,RC,61314-0044-75,NDC,outpatient,7.5,ML,948.02,663.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,24208-0315-10,NDC,outpatient,10,ML,47.84,33.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,61314-0628-10,NDC,outpatient,10,ML,43.88,30.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TABS,RX-11599,CDM,S5000,HCPCS,259,RC,00904-2725-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-01,NDC,outpatient,1,UN,15.37,10.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-11,NDC,outpatient,1,UN,15.37,10.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-01,NDC,outpatient,1,UN,11.52,8.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-10,NDC,outpatient,1,UN,11.52,8.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-01,NDC,outpatient,1,UN,41.49,29.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-10,NDC,outpatient,1,UN,41.49,29.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,RX-116728,CDM,S5000,HCPCS,259,RC,00597-0024-02,NDC,outpatient,4,GR,2012.08,1408.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIDOVUDINE 100 MG ORAL CAPS,RX-11692,CDM,S5000,HCPCS,259,RC,65862-0107-01,NDC,outpatient,1,UN,6.23,4.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIDOVUDINE 10 MG/ML ORAL SYRP,RX-11693,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,3.1,2.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZOLPIDEM TARTRATE 5 MG ORAL TABS,RX-11701,CDM,S5000,HCPCS,259,RC,00904-6082-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LINACLOTIDE 145 MCG ORAL CAPS,RX-117352,CDM,S5000,HCPCS,259,RC,00456-1201-30,NDC,outpatient,1,UN,74.11,51.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-93,NDC,outpatient,1,UN,6.86,4.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-07,NDC,outpatient,1,UN,8.83,6.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-16,NDC,outpatient,1,UN,6.86,4.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-01,NDC,outpatient,1,UN,8.83,6.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-01,NDC,outpatient,1,UN,1.46,1.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-23,NDC,outpatient,1,UN,4.35,3.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00904-6558-61,NDC,outpatient,1,UN,5.15,3.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-62,NDC,outpatient,1,UN,4.35,3.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-21,NDC,outpatient,1,UN,6.17,4.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-31,NDC,outpatient,1,UN,6.17,4.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-03,NDC,outpatient,10,ML,102.35,71.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-01,NDC,outpatient,10,ML,30.13,21.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-10,NDC,outpatient,10,ML,30.13,21.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-10,NDC,outpatient,10,ML,30.26,21.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-01,NDC,outpatient,10,ML,102.35,71.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-11,NDC,outpatient,10,ML,30.26,21.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,63304-0450-01,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-62,NDC,outpatient,1,UN,2.2,1.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00228-4270-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-23,NDC,outpatient,1,UN,2.2,1.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-23,NDC,outpatient,1,UN,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-62,NDC,outpatient,1,UN,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-02,NDC,outpatient,10,ML,3.96,2.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-28,NDC,outpatient,10,ML,3.96,2.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5649-01,NDC,outpatient,10,ML,39.65,27.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-09,NDC,outpatient,10,ML,3.96,2.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
APIXABAN 5 MG ORAL TABS,RX-119614,CDM,S5000,HCPCS,259,RC,00003-0894-31,NDC,outpatient,1,UN,6.17,4.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-32,NDC,outpatient,1,UN,23.14,16.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,00023-5853-18,NDC,outpatient,1,UN,15.96,11.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,59762-0117-01,NDC,outpatient,1,UN,10.4,7.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-33,NDC,outpatient,1,UN,23.14,16.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-01,NDC,outpatient,1,UN,1.73,1.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-11,NDC,outpatient,1,UN,1.73,1.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,68462-0721-01,NDC,outpatient,1,UN,5.92,4.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,62332-0025-31,NDC,outpatient,1,UN,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL ER 14 MG ORAL CP24,RX-121474,CDM,S5000,HCPCS,259,RC,00456-3414-33,NDC,outpatient,1,UN,7.56,5.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL ER 21 MG ORAL CP24,RX-121475,CDM,S5000,HCPCS,259,RC,00456-3421-33,NDC,outpatient,1,UN,7.56,5.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL ER 28 MG ORAL CP24,RX-121476,CDM,S5000,HCPCS,259,RC,00456-3428-33,NDC,outpatient,1,UN,63.71,44.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,55494-0100-10,NDC,outpatient,1,UN,13.41,9.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,70505-0100-10,NDC,outpatient,1,UN,13.18,9.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
QUINIDINE GLUCONATE ER 324 MG ORAL TBCR,RX-12197,CDM,S5000,HCPCS,259,RC,53489-0141-01,NDC,outpatient,1,UN,24.15,16.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-25,NDC,outpatient,1,UN,3.98,2.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-95,NDC,outpatient,1,UN,3.98,2.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,57664-0395-88,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-01,NDC,outpatient,1,UN,3.02,2.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-11,NDC,outpatient,1,UN,3.02,2.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-11,NDC,outpatient,1,UN,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-01,NDC,outpatient,1,UN,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-39,NDC,outpatient,2.5,ML,560.63,392.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-40,NDC,outpatient,2.5,ML,560.63,392.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IRON-VITAMIN C 65-125 MG ORAL TABS,RX-122332,CDM,S5000,HCPCS,259,RC,63736-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL ER 10 MG ORAL T12A,RX-122363,CDM,S5000,HCPCS,259,RC,59011-0410-20,NDC,outpatient,1,UN,22.52,15.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-10,NDC,outpatient,1,UN,40.9,28.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-20,NDC,outpatient,1,UN,41.94,29.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL ER 40 MG ORAL T12A,RX-122368,CDM,S5000,HCPCS,259,RC,59011-0440-20,NDC,outpatient,1,UN,71.8,50.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOLUTEGRAVIR SODIUM 50 MG ORAL TABS,RX-122784,CDM,S5000,HCPCS,259,RC,49702-0228-13,NDC,outpatient,1,UN,324.81,227.367,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,16729-0348-10,NDC,outpatient,1,UN,5,3.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,65162-0082-03,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-25,NDC,outpatient,4,ML,26.92,18.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-04,NDC,outpatient,4,ML,17.02,11.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-22,NDC,outpatient,4,ML,17.02,11.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-01,NDC,outpatient,4,ML,26.92,18.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-22,NDC,outpatient,30,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-30,NDC,outpatient,30,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-03,NDC,outpatient,30,ML,57.68,40.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-11,NDC,outpatient,30,ML,57.68,40.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-61,NDC,outpatient,3,ML,9.75,6.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-60,NDC,outpatient,3,ML,9.75,6.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-03,NDC,outpatient,2,ML,9.94,6.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-03,NDC,outpatient,2,ML,11.79,8.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-02,NDC,outpatient,2,ML,21.6,15.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-42,NDC,outpatient,2,ML,21.6,15.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-02,NDC,outpatient,2,ML,11.79,8.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-41,NDC,outpatient,2,ML,9.94,6.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,99999-0004-13,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,51672-4070-08,NDC,outpatient,2.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,61314-0643-05,NDC,outpatient,5,ML,42.15,29.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,70069-0131-01,NDC,outpatient,5,ML,22.25,15.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EXENATIDE 5 MCG/0.02ML SC SOPN,RX-124738,CDM,S5000,HCPCS,259,RC,00310-6512-01,NDC,outpatient,1.2,ML,2102.55,1471.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EXENATIDE 10 MCG/0.04ML SC SOPN,RX-124739,CDM,S5000,HCPCS,259,RC,00310-6524-01,NDC,outpatient,2.4,ML,2102.55,1471.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-12,NDC,outpatient,3,ML,1117.4,782.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-13,NDC,outpatient,3,ML,1117.41,782.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,00555-0899-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,42806-0087-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN 0.3 % OP OINT,RX-125351,CDM,S5000,HCPCS,259,RC,00078-0813-01,NDC,outpatient,3.5,GR,1047.63,733.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL LIQD,RX-12556,CDM,S5000,HCPCS,259,RC,00904-6985-20,NDC,outpatient,2.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-79,NDC,outpatient,2.5,ML,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,76204-0100-01,NDC,outpatient,2.5,ML,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-83,NDC,outpatient,2.5,ML,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00378-7970-93,NDC,outpatient,2.5,ML,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-01,NDC,outpatient,2.5,ML,1.51,1.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-60,NDC,outpatient,2.5,ML,1.12,0.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-125849,CDM,S5000,HCPCS,259,RC,00536-1186-12,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAFFEINE 200 MG ORAL TABS,RX-1259,CDM,S5000,HCPCS,259,RC,46017-0018-40,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DANTROLENE SODIUM 250 MG IV SUSR,RX-126042,CDM,S5000,HCPCS,250,RC,42367-0540-32,NDC,outpatient,1,UN,5868.29,4107.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-30,NDC,outpatient,1,UN,55.29,38.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-37,NDC,outpatient,1,UN,55.29,38.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EMPAGLIFLOZIN 25 MG ORAL TABS,RX-126078,CDM,S5000,HCPCS,259,RC,00597-0153-37,NDC,outpatient,1,UN,55.29,38.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-01,NDC,outpatient,2,ML,107.33,75.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-10,NDC,outpatient,2,ML,107.33,75.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TERBINAFINE HCL 250 MG ORAL TABS,RX-12724,CDM,S5000,HCPCS,259,RC,65862-0079-30,NDC,outpatient,1,UN,1.29,0.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMTERENE-HCTZ 37.5-25 MG ORAL CAPS,RX-12729,CDM,S5000,HCPCS,259,RC,00781-2074-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE IN NACL 20-0.9 MG/50ML-% IV SOLN,RX-12735,CDM,S5000,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-04,NDC,outpatient,5,ML,13.49,9.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-04,NDC,outpatient,5,ML,45.71,31.997,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,99999-0002-29,NDC,outpatient,5,ML,70.67,49.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-05,NDC,outpatient,5,ML,13.49,9.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-05,NDC,outpatient,5,ML,45.71,31.997,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE 7.5 MCG/HR TD PTWK,RX-127562,CDM,S5000,HCPCS,259,RC,42858-0353-40,NDC,outpatient,1,UN,309.07,216.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-25,NDC,outpatient,1,UN,10.51,7.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,00527-1313-01,NDC,outpatient,1,UN,4.2,2.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-95,NDC,outpatient,1,UN,10.51,7.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,RX-128423,CDM,S5000,HCPCS,259,RC,00597-0100-51,NDC,outpatient,4,GR,308.39,215.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENTOSAN POLYSULFATE SODIUM 100 MG ORAL CAPS,RX-12912,CDM,S5000,HCPCS,259,RC,50458-0098-01,NDC,outpatient,1,UN,46.46,32.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,00904-7097-61,NDC,outpatient,1,UN,4.43,3.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-20,NDC,outpatient,1,UN,4.95,3.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-01,NDC,outpatient,1,UN,4.95,3.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOMEBORO EX PACK,RX-129475,CDM,S5000,HCPCS,259,RC,57074-0001-77,NDC,outpatient,1,UN,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DARUNAVIR-COBICISTAT 800-150 MG ORAL TABS,RX-129730,CDM,S5000,HCPCS,259,RC,59676-0575-30,NDC,outpatient,1,UN,354.92,248.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-95,NDC,outpatient,2,ML,130.52,91.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-72,NDC,outpatient,2,ML,130.52,91.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-01,NDC,outpatient,1,UN,42.28,29.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-24,NDC,outpatient,1,UN,23.2,16.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-04,NDC,outpatient,1,UN,23.54,16.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-90,NDC,outpatient,1,UN,23.54,16.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-14,NDC,outpatient,4,ML,23.45,16.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-07,NDC,outpatient,4,ML,19.72,13.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-01,NDC,outpatient,4,ML,15.67,10.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,25021-0316-04,NDC,outpatient,4,ML,19.53,13.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-04,NDC,outpatient,4,ML,24.37,17.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-10,NDC,outpatient,4,ML,15.67,10.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-04,NDC,outpatient,4,ML,23.45,16.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-00,NDC,outpatient,4,ML,24.37,17.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-01,NDC,outpatient,4,ML,19.72,13.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,20555-0005-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,00904-3232-92,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,00536-1202-07,NDC,outpatient,1,UN,3.11,2.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,70512-0812-30,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,41167-0058-40,NDC,outpatient,1,UN,6.13,4.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,59762-1210-03,NDC,outpatient,1,UN,2.76,1.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,68180-0604-06,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-11,NDC,outpatient,10,ML,55.67,38.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-40,NDC,outpatient,10,ML,41.92,29.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-10,NDC,outpatient,10,ML,41.92,29.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-34,NDC,outpatient,10,ML,55.67,38.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,76329-3304-01,NDC,outpatient,10,ML,39.08,27.356,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-11,NDC,outpatient,1,UN,5.2,3.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-01,NDC,outpatient,1,UN,5.2,3.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,68462-0260-01,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-131078,CDM,S5000,HCPCS,259,RC,00597-0155-70,NDC,outpatient,4,GR,308.39,215.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,00904-5823-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG ORAL TABS,RX-131233,CDM,S5000,HCPCS,259,RC,61958-1901-01,NDC,outpatient,1,UN,572.84,400.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,00904-6565-61,NDC,outpatient,1,UN,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,63739-0077-10,NDC,outpatient,1,UN,4,2.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-11,NDC,outpatient,1,UN,4.3,3.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-01,NDC,outpatient,1,UN,4.3,3.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SACUBITRIL-VALSARTAN 24-26 MG ORAL TABS,RX-131630,CDM,S5000,HCPCS,259,RC,00078-0659-20,NDC,outpatient,1,UN,46.68,32.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SACUBITRIL-VALSARTAN 49-51 MG ORAL TABS,RX-131631,CDM,S5000,HCPCS,259,RC,00078-0777-20,NDC,outpatient,1,UN,46.68,32.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SACUBITRIL-VALSARTAN 97-103 MG ORAL TABS,RX-131632,CDM,S5000,HCPCS,259,RC,00078-0696-20,NDC,outpatient,1,UN,46.68,32.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMINOCAPROIC ACID 0.25 GM/ML ORAL SOLN,RX-131645,CDM,S5000,HCPCS,259,RC,99999-0001-90,NDC,outpatient,5,ML,202.39,141.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL ER 120 MG ORAL TBCR,RX-13184,CDM,S5000,HCPCS,259,RC,68462-0292-01,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE (PF) 0.75% -1:200000 IJ SOLN,RX-132205,CDM,S5000,HCPCS,250,RC,63323-0460-37,NDC,outpatient,30,ML,34.71,24.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TICAGRELOR 60 MG ORAL TABS,RX-132286,CDM,S5000,HCPCS,259,RC,00186-0776-60,NDC,outpatient,1,UN,30.77,21.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,69374-0982-55,NDC,outpatient,5,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-1119-44,NDC,outpatient,5,ML,20.39,14.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70004-0430-09,NDC,outpatient,5,ML,28.93,20.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-9119-44,NDC,outpatient,5,ML,27.82,19.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,00904-7119-06,NDC,outpatient,1,UN,3.29,2.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-01,NDC,outpatient,1,UN,5.45,3.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-11,NDC,outpatient,1,UN,5.45,3.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-60,NDC,outpatient,1,UN,29.34,20.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-01,NDC,outpatient,1,UN,29.34,20.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-60,NDC,outpatient,1,UN,46.07,32.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-01,NDC,outpatient,1,UN,46.07,32.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-01,NDC,outpatient,1,UN,70.24,49.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-60,NDC,outpatient,1,UN,70.24,49.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-01,NDC,outpatient,1,UN,72.31,50.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-60,NDC,outpatient,1,UN,72.31,50.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRENATAL VITAMIN PLUS LOW IRON 27-1 MG ORAL TABS,RX-133380,CDM,S5000,HCPCS,259,RC,39328-0106-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMCICLOVIR 500 MG ORAL TABS,RX-13358,CDM,S5000,HCPCS,259,RC,60505-3247-03,NDC,outpatient,1,UN,1.93,1.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,14.6,10.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,14.6,10.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-01,NDC,outpatient,3,ML,1168.7,818.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-27,NDC,outpatient,3,ML,1168.7,818.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EMTRICITABINE-TENOFOVIR AF 200-25 MG ORAL TABS,RX-134420,CDM,S5000,HCPCS,259,RC,61958-2002-01,NDC,outpatient,1,UN,316.88,221.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70004-0540-35,NDC,outpatient,125,ML,123.38,86.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1007-36,NDC,outpatient,125,ML,77.9,54.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1575-36,NDC,outpatient,125,ML,81.02,56.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PSYLLIUM 400 MG ORAL CAPS,RX-134482,CDM,S5000,HCPCS,259,RC,37000-0405-14,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-01,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-11,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,00904-3854-61,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE 100 MG/5ML ORAL SUSP,RX-1356,CDM,S5000,HCPCS,259,RC,99999-0001-92,NDC,outpatient,10,ML,6.06,4.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-01,NDC,outpatient,10,ML,411.18,287.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-05,NDC,outpatient,10,ML,411.18,287.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE 200 MG ORAL TABS,RX-1357,CDM,S5000,HCPCS,259,RC,00904-6172-61,NDC,outpatient,1,UN,2.42,1.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70004-0725-05,NDC,outpatient,1,ML,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,99999-0003-11,NDC,outpatient,1.1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70092-1443-43,NDC,outpatient,1,ML,22.08,15.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70004-0924-59,NDC,outpatient,280,ML,189.24,132.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,99999-0001-84,NDC,outpatient,280,ML,33.42,23.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70092-9056-05,NDC,outpatient,280,ML,121.34,84.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,00904-6627-35,NDC,outpatient,15,ML,6.35,4.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-23,NDC,outpatient,15,ML,15.56,10.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-21,NDC,outpatient,15,ML,17.89,12.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-11,NDC,outpatient,1,UN,5.12,3.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,00054-8550-25,NDC,outpatient,1,UN,5.49,3.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-15,NDC,outpatient,1,UN,5.12,3.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-136367,CDM,S5000,HCPCS,250,RC,44567-0601-04,NDC,outpatient,10,ML,205.59,143.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,11701-0067-23,NDC,outpatient,57,GR,25.88,18.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,53329-0172-10,NDC,outpatient,71,GR,15.17,10.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70004-0923-59,NDC,outpatient,275,ML,170.02,119.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,99999-0001-85,NDC,outpatient,275,ML,59.61,41.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70092-9054-05,NDC,outpatient,275,ML,111.55,78.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,71506-0015-58,NDC,outpatient,275,ML,93.39,65.373,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-15,NDC,outpatient,15,ML,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-00,NDC,outpatient,15,ML,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,76154-0818-05,NDC,outpatient,125,ML,82.75,57.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,99999-0003-40,NDC,outpatient,125,ML,51.6,36.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1068-07,NDC,outpatient,500,ML,106.3,74.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1552-07,NDC,outpatient,500,ML,97.53,68.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LINACLOTIDE 72 MCG ORAL CAPS,RX-138008,CDM,S5000,HCPCS,259,RC,00456-1203-30,NDC,outpatient,1,UN,74.11,51.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,57896-0145-14,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,58980-0011-10,NDC,outpatient,28.35,GR,10.1,7.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,00536-1263-28,NDC,outpatient,28,GR,4.99,3.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,71506-0019-59,NDC,outpatient,540,ML,128.46,89.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,99999-0002-01,NDC,outpatient,540,ML,36.84,25.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,71506-0017-59,NDC,outpatient,535,ML,119.16,83.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,99999-0002-00,NDC,outpatient,535,ML,35.39,24.773,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZOCAINE 20 % MT AERO,RX-138339,CDM,S5000,HCPCS,259,RC,00283-0679-02,NDC,outpatient,57,GR,120.74,84.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP,RX-138354,CDM,S5000,HCPCS,250,RC,10122-0510-01,NDC,outpatient,1.5,ML,1807.78,1265.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,RX-138355,CDM,S5000,HCPCS,250,RC,10122-0510-03,NDC,outpatient,3,ML,2153.49,1507.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00115-5211-16,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-11,NDC,outpatient,1,UN,12.93,9.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00009-0450-03,NDC,outpatient,1,UN,9.24,6.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,59762-0450-01,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-21,NDC,outpatient,1,UN,12.93,9.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1380-36,NDC,outpatient,100,ML,69.27,48.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1130-36,NDC,outpatient,100,ML,83.73,58.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,99999-0003-24,NDC,outpatient,100,ML,48.85,34.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,66993-0456-30,NDC,outpatient,1,UN,54.61,38.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,00310-6205-30,NDC,outpatient,1,UN,54.15,37.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,00310-6210-39,NDC,outpatient,1,UN,54.15,37.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,66993-0457-30,NDC,outpatient,1,UN,57.77,40.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,24208-0387-62,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,00536-5090-08,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-00,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARISOPRODOL 350 MG ORAL TABS,RX-1395,CDM,S5000,HCPCS,259,RC,50228-0109-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,00904-7007-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,51672-4130-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,00904-7008-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,51672-4131-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CARBONATE ANTACID 1250 MG/5ML ORAL SUSP,RX-140541,CDM,S5000,HCPCS,259,RC,00121-4766-05,NDC,outpatient,5,ML,9.19,6.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-01,NDC,outpatient,1,UN,13.61,9.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-20,NDC,outpatient,1,UN,13.61,9.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-20,NDC,outpatient,1,UN,16,11.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-01,NDC,outpatient,1,UN,16,11.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,S5000,HCPCS,259,RC,45802-0465-64,NDC,outpatient,120,ML,53.4,37.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,RX-141345,CDM,S5000,HCPCS,259,RC,59310-0302-40,NDC,outpatient,10.6,GR,878.5,614.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,RX-141346,CDM,S5000,HCPCS,259,RC,59310-0304-80,NDC,outpatient,10.6,GR,1176.28,823.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG ORAL TABS,RX-142007,CDM,S5000,HCPCS,259,RC,61958-2501-01,NDC,outpatient,1,UN,572.84,400.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,16714-0696-01,NDC,outpatient,35,ML,43.77,30.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,99999-0002-78,NDC,outpatient,5,ML,12.62,8.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,59762-5030-01,NDC,outpatient,35,ML,84.73,59.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,57896-0635-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,68585-0005-75,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,10006-0700-13,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,71740-0112-30,NDC,outpatient,0.25,ML,14.74,10.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,99999-0003-49,NDC,outpatient,1,ML,58.94,41.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG ORAL TABS,RX-143657,CDM,S5000,HCPCS,259,RC,59676-0800-30,NDC,outpatient,1,UN,678.69,475.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PIMAVANSERIN TARTRATE 34 MG ORAL CAPS,RX-143683,CDM,S5000,HCPCS,259,RC,63090-0340-30,NDC,outpatient,1,UN,740.93,518.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-01,NDC,outpatient,1,UN,69.73,48.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-39,NDC,outpatient,1,UN,69.73,48.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-16,NDC,outpatient,1,UN,58.96,41.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-99,NDC,outpatient,1,UN,58.96,41.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,52817-0610-04,NDC,outpatient,1,UN,36.6,25.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,82089-0102-34,NDC,outpatient,1,UN,502.38,351.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-54,NDC,outpatient,1,UN,89.34,62.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-04,NDC,outpatient,1,UN,43.76,30.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-04,NDC,outpatient,1,UN,89.34,62.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-01,NDC,outpatient,1,UN,43.76,30.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-04,NDC,outpatient,1,UN,122.13,85.491,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-54,NDC,outpatient,1,UN,122.13,85.491,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,24208-0485-10,NDC,outpatient,10,ML,36.09,25.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,42571-0141-26,NDC,outpatient,10,ML,151.26,105.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,61314-0019-10,NDC,outpatient,10,ML,71.78,50.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-32,NDC,outpatient,3,ML,93.63,65.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-93,NDC,outpatient,3,ML,93.63,65.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-15,NDC,outpatient,1,UN,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-11,NDC,outpatient,1,UN,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-15,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-11,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-02,NDC,outpatient,5,ML,2091.2,1463.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-15,NDC,outpatient,5,ML,2091.2,1463.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,99999-0002-40,NDC,outpatient,5,ML,47,32.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,69238-1731-02,NDC,outpatient,473,ML,2201.68,1541.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL ER 180 MG ORAL TBCR,RX-14626,CDM,S5000,HCPCS,259,RC,75834-0158-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-11,NDC,outpatient,1,UN,9.29,6.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-21,NDC,outpatient,1,UN,9.29,6.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00904-7179-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00093-0058-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,29300-0355-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETIC ACID 5 % SOLN,RX-14702,CDM,S5000,HCPCS,259,RC,99999-0000-92,NDC,outpatient,60,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,00904-7163-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLYBURIDE MICRONIZED 1.5 MG ORAL TABS,RX-14777,CDM,S5000,HCPCS,259,RC,00093-8034-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147794,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-03,NDC,outpatient,100,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-01,NDC,outpatient,100,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-01,NDC,outpatient,1,UN,14.17,9.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-30,NDC,outpatient,1,UN,14.17,9.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-11,NDC,outpatient,1,UN,2.93,2.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-15,NDC,outpatient,1,UN,2.93,2.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIZANIDINE HCL 4 MG ORAL TABS,RX-14793,CDM,S5000,HCPCS,259,RC,00904-6418-61,NDC,outpatient,1,UN,1.85,1.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-88,NDC,outpatient,1,UN,22.99,16.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-77,NDC,outpatient,1,UN,20.73,14.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-32,NDC,outpatient,1,UN,22.99,16.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,64764-0544-11,NDC,outpatient,1,UN,56.9,39.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-30,NDC,outpatient,1,UN,20.73,14.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-01,NDC,outpatient,1,UN,1.75,1.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-11,NDC,outpatient,1,UN,1.75,1.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,00904-7048-61,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-15,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-11,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,69097-0579-67,NDC,outpatient,1,UN,204.35,143.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-94,NDC,outpatient,1,UN,214.58,150.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-99,NDC,outpatient,1,UN,214.58,150.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,70748-0299-01,NDC,outpatient,210,ML,615.84,431.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,99999-0004-54,NDC,outpatient,5,ML,14.67,10.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-03,NDC,outpatient,30,ML,8.02,5.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-01,NDC,outpatient,30,ML,8.02,5.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MOEXIPRIL HCL 7.5 MG ORAL TABS,RX-15025,CDM,S5000,HCPCS,259,RC,68462-0209-01,NDC,outpatient,1,UN,3.46,2.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0140-03,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,00904-2085-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0101-44,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORT-PRAMOXINE (PERIANAL) 2.5-1 % EX CREA,RX-150325,CDM,S5000,HCPCS,259,RC,45802-0472-64,NDC,outpatient,30,GR,583,408.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,99999-0001-49,NDC,outpatient,60,ML,11.75,8.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,51552-0051-06,NDC,outpatient,500,ML,97.9,68.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-59,NDC,outpatient,15,ML,10.55,7.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-62,NDC,outpatient,15,ML,10.55,7.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-01,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-20,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-01,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-11,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,99999-0001-69,NDC,outpatient,0.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,00087-0405-01,NDC,outpatient,0.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TACROLIMUS ER 1 MG ORAL TB24,RX-151676,CDM,S5000,HCPCS,259,RC,68992-3010-03,NDC,outpatient,1,UN,3.04,2.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TACROLIMUS ER 0.75 MG ORAL TB24,RX-151678,CDM,S5000,HCPCS,259,RC,68992-3075-03,NDC,outpatient,1,UN,2.28,1.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TACROLIMUS ER 4 MG ORAL TB24,RX-151679,CDM,S5000,HCPCS,259,RC,68992-3040-03,NDC,outpatient,1,UN,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-10,NDC,outpatient,10,ML,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,99999-0002-42,NDC,outpatient,10,ML,1.6,1.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-59,NDC,outpatient,10,ML,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-08,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-10,NDC,outpatient,10,ML,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-01,NDC,outpatient,1,ML,93.05,65.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-25,NDC,outpatient,1,ML,93.05,65.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHACHOLINE CHLORIDE IN KIT,RX-151916,CDM,S5000,HCPCS,259,RC,69374-0542-06,NDC,outpatient,18,ML,600.75,420.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,00536-1294-97,NDC,outpatient,100,GR,33.38,23.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,69097-0524-44,NDC,outpatient,100,GR,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,43598-0977-10,NDC,outpatient,100,GR,59.19,41.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUMATRIPTAN SUCCINATE 25 MG ORAL TABS,RX-15327,CDM,S5000,HCPCS,259,RC,65862-0146-36,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,00228-2550-11,NDC,outpatient,1,UN,1.63,1.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-11,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,16571-0202-10,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,61442-0102-01,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-01,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 75 MG ORAL TBEC,RX-15341,CDM,S5000,HCPCS,259,RC,16571-0201-06,NDC,outpatient,1,UN,1.46,1.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,00225-0525-47,NDC,outpatient,14.1,GR,10.92,7.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,05928-0000-99,NDC,outpatient,28.4,GR,22.75,15.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIMANTADINE HCL 100 MG ORAL TABS,RX-15440,CDM,S5000,HCPCS,259,RC,00115-1911-01,NDC,outpatient,1,UN,10.21,7.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHERRY ORAL SYRP,RX-1562,CDM,S5000,HCPCS,259,RC,00395-2662-16,NDC,outpatient,473,ML,78.58,55.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-09,NDC,outpatient,250,ML,59.39,41.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-13,NDC,outpatient,500,ML,73.85,51.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMANTADINE HCL 50 MG/5ML ORAL SOLN,RX-156382,CDM,S5000,HCPCS,259,RC,00121-0646-10,NDC,outpatient,10,ML,13.67,9.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALENDRONATE SODIUM 10 MG ORAL TABS,RX-15661,CDM,S5000,HCPCS,259,RC,16714-0631-01,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156724,CDM,S5000,HCPCS,250,RC,60267-0705-50,NDC,outpatient,50,ML,431.65,302.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN,RX-156740,CDM,S5000,HCPCS,250,RC,24571-0108-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN,RX-156741,CDM,S5000,HCPCS,250,RC,24571-0105-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN,RX-156742,CDM,S5000,HCPCS,250,RC,24571-0102-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L EC SOLN,RX-156743,CDM,S5000,HCPCS,250,RC,24571-0103-06,NDC,outpatient,5000,ML,325.06,227.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,00093-1060-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,60505-0159-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,60505-0823-06,NDC,outpatient,3.7,ML,230.15,161.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,49884-0161-11,NDC,outpatient,3.7,ML,207.33,145.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARVEDILOL 6.25 MG ORAL TABS,RX-15747,CDM,S5000,HCPCS,259,RC,00904-6301-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,00904-6302-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,68382-0094-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,59762-3120-01,NDC,outpatient,18.75,ML,76.85,53.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,00093-2026-23,NDC,outpatient,18.75,ML,62.17,43.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,99999-0002-81,NDC,outpatient,6.25,ML,21.03,14.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DARUNAVIR 800 MG ORAL TABS,RX-158170,CDM,S5000,HCPCS,259,RC,59676-0566-30,NDC,outpatient,1,UN,310.53,217.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00002-7533-01,NDC,outpatient,3,ML,80.06,56.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5924-10,NDC,outpatient,10,ML,322.63,225.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5926-05,NDC,outpatient,3,ML,50.03,35.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,00904-6583-04,NDC,outpatient,1,UN,21.27,14.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,64380-0710-03,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LAMIVUDINE 10 MG/ML ORAL SOLN,RX-15881,CDM,S5000,HCPCS,259,RC,54838-0566-70,NDC,outpatient,15,ML,23.1,16.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACARBOSE 50 MG ORAL TABS,RX-15895,CDM,S5000,HCPCS,259,RC,64380-0759-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,S5000,HCPCS,259,RC,00436-0936-16,NDC,outpatient,473,ML,52.63,36.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-02,NDC,outpatient,1,UN,571.55,400.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-20,NDC,outpatient,1,UN,3544.84,2481.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-30,NDC,outpatient,1,UN,3544.84,2481.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-03,NDC,outpatient,1,UN,571.55,400.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,00406-0527-10,NDC,outpatient,0.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,99999-0002-10,NDC,outpatient,10,ML,27.28,19.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-160113,CDM,S5000,HCPCS,259,RC,00046-0872-21,NDC,outpatient,30,GR,1850.58,1295.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,S5000,HCPCS,259,RC,16714-0763-01,NDC,outpatient,60,GR,327.35,229.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-11,NDC,outpatient,1,UN,3.58,2.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,80681-0100-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-51,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-11,NDC,outpatient,1,UN,7.9,5.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-21,NDC,outpatient,1,UN,7.9,5.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,23155-0490-01,NDC,outpatient,1,UN,1.27,0.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLENE BLUE 1 % IV SOLN,RX-160649,CDM,S5000,HCPCS,250,RC,54288-0147-01,NDC,outpatient,10,ML,616.77,431.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,00574-0520-74,NDC,outpatient,120,ML,51.8,36.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,66689-0203-04,NDC,outpatient,120,ML,73.16,51.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,00054-0045-44,NDC,outpatient,30,ML,160.2,112.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,24208-0398-30,NDC,outpatient,30,ML,45.66,31.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CARB-CHOLECALCIFEROL 600-5 MG-MCG ORAL TABS,RX-160700,CDM,S5000,HCPCS,259,RC,80681-0138-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,00054-0046-41,NDC,outpatient,15,ML,147.99,103.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,60505-0827-01,NDC,outpatient,15,ML,69.49,48.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMCICLOVIR 250 MG ORAL TABS,RX-16081,CDM,S5000,HCPCS,259,RC,60505-3246-03,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,00536-3223-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-03,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RILUZOLE 50 MG ORAL TABS,RX-16124,CDM,S5000,HCPCS,259,RC,67877-0286-60,NDC,outpatient,1,UN,2.96,2.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,00054-3120-41,NDC,outpatient,1,ML,24.45,17.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,99999-0002-71,NDC,outpatient,1,ML,19.3,13.51,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,63304-0241-59,NDC,outpatient,1,ML,19.3,13.51,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-20,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,00555-0159-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-01,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-20,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-01,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EUCERIN ORIGINAL HEALING EX CREA,RX-162713,CDM,S5000,HCPCS,259,RC,72140-0038-68,NDC,outpatient,57,GR,20.04,14.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-01,NDC,outpatient,1,UN,2.06,1.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,55111-0321-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-11,NDC,outpatient,1,UN,2.06,1.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPH-SHARK LIV OIL-MO-PET 0.25-3-14-71.9 % RE OINT,RX-16462,CDM,S5000,HCPCS,259,RC,00573-2871-93,NDC,outpatient,28,GR,25.8,18.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-11,NDC,outpatient,1,UN,4.66,3.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,00904-7129-61,NDC,outpatient,1,UN,10.41,7.287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-15,NDC,outpatient,1,UN,4.66,3.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,69238-1060-01,NDC,outpatient,1,UN,6.98,4.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,00904-7132-61,NDC,outpatient,1,UN,20.86,14.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-11,NDC,outpatient,1,UN,7.19,5.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,69238-1056-01,NDC,outpatient,1,UN,2.88,2.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-15,NDC,outpatient,1,UN,7.19,5.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00065-4011-05,NDC,outpatient,5,ML,42.77,29.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00536-1252-40,NDC,outpatient,5,ML,30.09,21.063,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,72485-0617-10,NDC,outpatient,5,ML,28.93,20.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-01,NDC,outpatient,1,UN,7.86,5.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-20,NDC,outpatient,1,UN,7.86,5.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-01,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,63739-0888-10,NDC,outpatient,1,UN,2.7,1.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-11,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERROUS SULFATE ER 45 MG ORAL TBCR,RX-167735,CDM,S5000,HCPCS,259,RC,10006-0730-13,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,S5000,HCPCS,250,RC,00942-0641-04,NDC,outpatient,1000,ML,60.15,42.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,20555-0036-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYOSCYAMINE SULFATE ER 0.375 MG ORAL TB12,RX-17010,CDM,S5000,HCPCS,259,RC,51525-0115-01,NDC,outpatient,1,UN,1.16,0.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANDOLAPRIL 1 MG ORAL TABS,RX-17017,CDM,S5000,HCPCS,259,RC,68180-0566-01,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SELEGILINE HCL 5 MG ORAL CAPS,RX-17280,CDM,S5000,HCPCS,259,RC,60505-0055-01,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,61924-0184-04,NDC,outpatient,106,GR,13.68,9.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0031-47,NDC,outpatient,396,GR,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0452-31,NDC,outpatient,50,GR,20.25,14.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,27808-0002-01,NDC,outpatient,0.25,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,99999-0003-81,NDC,outpatient,1,ML,4.12,2.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,65162-0673-84,NDC,outpatient,0.25,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AZITHROMYCIN 600 MG ORAL TABS,RX-17387,CDM,S5000,HCPCS,259,RC,62332-0253-30,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN HCL 150 MG ORAL CAPS,RX-1740,CDM,S5000,HCPCS,259,RC,00904-5959-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEVIRAPINE 200 MG ORAL TABS,RX-17403,CDM,S5000,HCPCS,259,RC,31722-0505-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,45802-0562-02,NDC,outpatient,60,ML,48.6,34.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,00168-0201-60,NDC,outpatient,60,ML,139.11,97.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,00904-6519-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,RX-17524,CDM,S5000,HCPCS,250,RC,59584-0138-01,NDC,outpatient,0.1,ML,121.71,85.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-01,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-11,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABS,RX-1759,CDM,S5000,HCPCS,259,RC,13107-0319-01,NDC,outpatient,1,UN,4.43,3.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,51672-2002-02,NDC,outpatient,30,GR,6.01,4.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,45802-0434-11,NDC,outpatient,30,GR,10.42,7.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,S5000,HCPCS,259,RC,51672-1260-03,NDC,outpatient,30,ML,97.86,68.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,S5000,HCPCS,259,RC,51672-2003-06,NDC,outpatient,45,GR,11.82,8.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,24208-0411-05,NDC,outpatient,5,ML,61.95,43.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,61314-0143-05,NDC,outpatient,5,ML,13.04,9.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,70069-0231-01,NDC,outpatient,5,ML,7.26,5.082,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,71921-0185-05,NDC,outpatient,5,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
B COMPLEX ORAL CAPS,RX-17882,CDM,S5000,HCPCS,259,RC,54629-0560-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 5 MG ORAL TABS,RX-17936,CDM,S5000,HCPCS,259,RC,00904-6377-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXAMETHASONE 1 MG/ML ORAL CONC,RX-17946,CDM,S5000,HCPCS,259,RC,00054-3176-44,NDC,outpatient,30,ML,90.92,63.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-11,NDC,outpatient,1,UN,10.83,7.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-21,NDC,outpatient,1,UN,10.83,7.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,S5000,HCPCS,259,RC,45802-0513-77,NDC,outpatient,140,GR,35.52,24.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CODEINE SULFATE 15 MG ORAL TABS,RX-1801,CDM,S5000,HCPCS,259,RC,00054-0243-24,NDC,outpatient,1,UN,2.94,2.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNA 8.6 MG ORAL TABS,RX-18138,CDM,S5000,HCPCS,259,RC,00904-7252-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-03,NDC,outpatient,1,UN,13.56,9.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,65162-0710-09,NDC,outpatient,1,UN,2.83,1.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-01,NDC,outpatient,1,UN,13.56,9.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISOPROLOL FUMARATE 5 MG ORAL TABS,RX-18288,CDM,S5000,HCPCS,259,RC,29300-0126-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,29300-0189-01,NDC,outpatient,1,UN,2.16,1.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,10135-0742-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG ORAL TABS,RX-18290,CDM,S5000,HCPCS,259,RC,29300-0188-01,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,68462-0878-30,NDC,outpatient,1,UN,1.61,1.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,29300-0187-01,NDC,outpatient,1,UN,2.03,1.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-11,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-15,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-11,NDC,outpatient,1,UN,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-11,NDC,outpatient,1,UN,1.28,0.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-01,NDC,outpatient,1,UN,1.28,0.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-25,NDC,outpatient,1,UN,1.1,0.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-29,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-15,NDC,outpatient,1,UN,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-11,NDC,outpatient,1,UN,1.64,1.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,31722-0532-01,NDC,outpatient,1,UN,2.32,1.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-15,NDC,outpatient,1,UN,1.64,1.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,00904-6667-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,63739-0904-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,16714-0662-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,00904-6666-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,45963-0556-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,63739-0903-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,00904-6665-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,63739-0902-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 2 MG ORAL TABS,RX-18311,CDM,S5000,HCPCS,259,RC,00904-7363-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,00904-7362-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,42291-0910-60,NDC,outpatient,1,UN,11.7,8.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-11,NDC,outpatient,1,UN,2.72,1.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-01,NDC,outpatient,1,UN,2.72,1.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-25,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-95,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-01,NDC,outpatient,1,UN,164.07,114.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-03,NDC,outpatient,1,UN,164.48,115.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-10,NDC,outpatient,1,UN,164.07,114.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-01,NDC,outpatient,1,UN,164.48,115.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARVEDILOL 3.125 MG ORAL TABS,RX-18551,CDM,S5000,HCPCS,259,RC,00904-6300-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,61314-0547-01,NDC,outpatient,2.5,ML,19.1,13.37,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,59762-0333-02,NDC,outpatient,2.5,ML,18.92,13.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,24208-0463-25,NDC,outpatient,2.5,ML,46.77,32.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,70069-0421-01,NDC,outpatient,2.5,ML,19.9,13.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DONEPEZIL HCL 5 MG ORAL TABS,RX-18786,CDM,S5000,HCPCS,259,RC,00904-6477-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,67457-0839-02,NDC,outpatient,2,ML,53.45,37.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,72485-0105-01,NDC,outpatient,2,ML,69.91,48.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,43598-0587-23,NDC,outpatient,2,ML,87.58,61.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOFLOXACIN 250 MG ORAL TABS,RX-18918,CDM,S5000,HCPCS,259,RC,00904-6351-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOFLOXACIN 500 MG ORAL TABS,RX-18919,CDM,S5000,HCPCS,259,RC,00904-6352-61,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-11,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-01,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-01,NDC,outpatient,1,UN,2.19,1.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-11,NDC,outpatient,1,UN,2.19,1.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATORVASTATIN CALCIUM 10 MG ORAL TABS,RX-19176,CDM,S5000,HCPCS,259,RC,00904-6290-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATORVASTATIN CALCIUM 20 MG ORAL TABS,RX-19178,CDM,S5000,HCPCS,259,RC,00904-6291-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,S5000,HCPCS,259,RC,60505-0833-05,NDC,outpatient,30,ML,24.97,17.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,50742-0118-08,NDC,outpatient,1,UN,13.91,9.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,23155-0823-73,NDC,outpatient,1,UN,8.36,5.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,59762-1005-01,NDC,outpatient,1,UN,22.17,15.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,S5000,HCPCS,259,RC,70756-0614-30,NDC,outpatient,5,ML,178,124.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZOCAINE 20 % MT GEL,RX-19691,CDM,S5000,HCPCS,259,RC,10310-0566-20,NDC,outpatient,11.9,GR,20.34,14.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,S5000,HCPCS,259,RC,00065-0023-15,NDC,outpatient,1.5,ML,66,46.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,00254-1010-19,NDC,outpatient,30,ML,1132.89,793.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,99999-0003-50,NDC,outpatient,1,ML,37.77,26.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,24208-0457-05,NDC,outpatient,5,ML,46.46,32.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,61314-0014-25,NDC,outpatient,2.5,ML,39.79,27.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,S5000,HCPCS,259,RC,11980-0228-05,NDC,outpatient,5,ML,692.51,484.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00009-0746-30,NDC,outpatient,1,ML,216.41,151.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00548-5400-00,NDC,outpatient,1,ML,75.65,52.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,49348-0541-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,00135-0199-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,60505-0560-00,NDC,outpatient,5,ML,32.22,22.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,64980-0515-05,NDC,outpatient,5,ML,58.61,41.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POVIDONE-IODINE 5 % OP SOLN,RX-19791,CDM,S5000,HCPCS,259,RC,00065-0411-30,NDC,outpatient,30,ML,45.26,31.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-POLYMYXIN-PRAMOXINE 1 % EX CREA,RX-19880,CDM,S5000,HCPCS,259,RC,12547-0407-40,NDC,outpatient,14.2,GR,19.03,13.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-01,NDC,outpatient,1,UN,1.26,0.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-11,NDC,outpatient,1,UN,1.26,0.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NELFINAVIR MESYLATE 250 MG ORAL TABS,RX-20032,CDM,S5000,HCPCS,259,RC,63010-0010-30,NDC,outpatient,1,UN,17.47,12.229,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESNA 400 MG ORAL TABS,RX-20077,CDM,S5000,HCPCS,259,RC,67108-3565-09,NDC,outpatient,1,UN,287.17,201.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-01,NDC,outpatient,2,ML,47.31,33.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-06,NDC,outpatient,15,ML,121.82,85.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-11,NDC,outpatient,1,UN,2.94,2.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-15,NDC,outpatient,1,UN,2.94,2.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-01,NDC,outpatient,10,ML,375.94,263.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-03,NDC,outpatient,10,ML,375.94,263.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,00172-5241-60,NDC,outpatient,1,UN,3.43,2.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,13668-0453-01,NDC,outpatient,1,UN,2.97,2.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-10,NDC,outpatient,10,ML,25.46,17.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,55150-0221-10,NDC,outpatient,10,ML,12.44,8.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-10,NDC,outpatient,10,ML,13.73,9.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-01,NDC,outpatient,20,ML,27.51,19.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-10,NDC,outpatient,20,ML,27.51,19.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-01,NDC,outpatient,10,ML,13.73,9.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-01,NDC,outpatient,10,ML,25.46,17.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX LIQD,RX-20781,CDM,S5000,HCPCS,259,RC,49348-0443-34,NDC,outpatient,118,ML,21.53,15.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIGLITOL 25 MG ORAL TABS,RX-20799,CDM,S5000,HCPCS,259,RC,69367-0303-01,NDC,outpatient,1,UN,7.35,5.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-01,NDC,outpatient,5,ML,9.31,6.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-01,NDC,outpatient,5,ML,20.56,14.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-10,NDC,outpatient,5,ML,20.56,14.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-05,NDC,outpatient,5,ML,9.31,6.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-05,NDC,outpatient,5,ML,10.16,7.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-41,NDC,outpatient,5,ML,10.16,7.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-11,NDC,outpatient,1,UN,3.5,2.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,65862-0641-63,NDC,outpatient,1,UN,1.45,1.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-01,NDC,outpatient,1,UN,3.5,2.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-01,NDC,outpatient,5,ML,94.7,66.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-10,NDC,outpatient,5,ML,94.7,66.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,54482-0147-01,NDC,outpatient,5,ML,99.51,69.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 2.5 MG ORAL TABS,RX-21057,CDM,S5000,HCPCS,259,RC,00904-6283-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-01,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-11,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,62756-0184-88,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CITALOPRAM HYDROBROMIDE 20 MG ORAL TABS,RX-21062,CDM,S5000,HCPCS,259,RC,00904-6085-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG ORAL TABS,RX-21284,CDM,S5000,HCPCS,259,RC,42806-0339-01,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-11,NDC,outpatient,1,UN,3.34,2.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-21,NDC,outpatient,1,UN,3.34,2.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG ORAL TABS,RX-21289,CDM,S5000,HCPCS,259,RC,68462-0334-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG ORAL TABS,RX-21290,CDM,S5000,HCPCS,259,RC,00904-6704-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,60505-0033-06,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,00904-5448-61,NDC,outpatient,1,UN,1.11,0.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAPSONE 100 MG ORAL TABS,RX-2131,CDM,S5000,HCPCS,259,RC,70954-0136-10,NDC,outpatient,1,UN,5.05,3.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAPSONE 25 MG ORAL TABS,RX-2132,CDM,S5000,HCPCS,259,RC,70954-0135-10,NDC,outpatient,1,UN,4.35,3.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,00078-0249-15,NDC,outpatient,1,UN,108.93,76.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,59651-0180-30,NDC,outpatient,1,UN,1.55,1.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR,RX-21672,CDM,S5000,HCPCS,250,RC,24338-0050-08,NDC,outpatient,8,UN,110831.48,77582.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROPINIROLE HCL 0.25 MG ORAL TABS,RX-21688,CDM,S5000,HCPCS,259,RC,00904-6373-61,NDC,outpatient,1,UN,1.51,1.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROPINIROLE HCL 1 MG ORAL TABS,RX-21689,CDM,S5000,HCPCS,259,RC,00904-6374-61,NDC,outpatient,1,UN,1.76,1.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-11,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-15,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,00904-6638-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
QUETIAPINE FUMARATE 100 MG ORAL TABS,RX-21824,CDM,S5000,HCPCS,259,RC,00904-6640-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TIAGABINE HCL 4 MG ORAL TABS,RX-21827,CDM,S5000,HCPCS,259,RC,62756-0224-83,NDC,outpatient,1,UN,16.11,11.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,33342-0048-10,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,31722-0730-90,NDC,outpatient,1,UN,1.91,1.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOPIDOGREL BISULFATE 75 MG ORAL TABS,RX-22142,CDM,S5000,HCPCS,259,RC,00904-6294-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-11,NDC,outpatient,1,UN,23.4,16.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-21,NDC,outpatient,1,UN,23.4,16.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-03,NDC,outpatient,1,UN,40.12,28.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-13,NDC,outpatient,1,UN,40.12,28.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-44,NDC,outpatient,5,ML,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-56,NDC,outpatient,5,ML,27.71,19.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-56,NDC,outpatient,5,ML,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-04,NDC,outpatient,5,ML,27.71,19.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,68462-0564-17,NDC,outpatient,15,GR,861.28,602.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,51672-1370-01,NDC,outpatient,15,GR,62.62,43.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,24208-0410-05,NDC,outpatient,5,ML,214.49,150.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,70756-0609-15,NDC,outpatient,5,ML,31.29,21.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-50,NDC,outpatient,1,UN,1.55,1.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,00904-5224-52,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-25,NDC,outpatient,1,UN,1.55,1.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-61,NDC,outpatient,1,UN,1.44,1.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-06,NDC,outpatient,1,UN,1.19,0.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-11,NDC,outpatient,1,UN,2.8,1.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-15,NDC,outpatient,1,UN,2.8,1.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-20,NDC,outpatient,20,ML,60.61,42.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-40,NDC,outpatient,20,ML,60.61,42.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,99999-0002-45,NDC,outpatient,20,ML,22.52,15.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
REPAGLINIDE 2 MG ORAL TABS,RX-22585,CDM,S5000,HCPCS,259,RC,65862-0672-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
REPAGLINIDE 1 MG ORAL TABS,RX-22586,CDM,S5000,HCPCS,259,RC,65862-0671-01,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,60258-0003-16,NDC,outpatient,10,ML,5.88,4.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,00121-0676-16,NDC,outpatient,15,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,99999-0002-34,NDC,outpatient,15,ML,3.14,2.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,68462-0473-01,NDC,outpatient,1,UN,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-11,NDC,outpatient,1,UN,6.99,4.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,00904-6890-04,NDC,outpatient,1,UN,10.99,7.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-21,NDC,outpatient,1,UN,6.99,4.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESIPRAMINE HCL 25 MG ORAL TABS,RX-2286,CDM,S5000,HCPCS,259,RC,50742-0113-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,70954-0319-10,NDC,outpatient,5,ML,32.69,22.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,99999-0001-34,NDC,outpatient,10,ML,72.98,51.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,65862-0946-01,NDC,outpatient,10,ML,89,62.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,71921-0226-10,NDC,outpatient,10,ML,45.39,31.773,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,82584-0605-10,NDC,outpatient,10,ML,996.05,697.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,70069-0051-01,NDC,outpatient,10,ML,38.99,27.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,24208-0486-10,NDC,outpatient,10,ML,45.62,31.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,00781-1874-31,NDC,outpatient,1,UN,6.58,4.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,42571-0160-30,NDC,outpatient,1,UN,9.65,6.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,16729-0073-29,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,00004-1101-50,NDC,outpatient,1,UN,195.05,136.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISEDRONATE SODIUM 30 MG ORAL TABS,RX-23015,CDM,S5000,HCPCS,259,RC,00093-3100-56,NDC,outpatient,1,UN,220.55,154.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,00536-1268-12,NDC,outpatient,222,ML,16.8,11.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,46122-0573-10,NDC,outpatient,222,ML,11.13,7.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINISOL SF 15 % IV SOLN,RX-23068,CDM,S5000,HCPCS,250,RC,00338-0502-06,NDC,outpatient,2000,ML,211.8,148.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1123-04,NDC,outpatient,2000,ML,211.8,148.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1147-03,NDC,outpatient,1000,ML,122.8,85.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXAMETHASONE 0.5 MG ORAL TABS,RX-2322,CDM,S5000,HCPCS,259,RC,00054-8179-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,33342-0114-07,NDC,outpatient,1,UN,5.64,3.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,62332-0341-90,NDC,outpatient,1,UN,4.08,2.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CANDESARTAN CILEXETIL 16 MG ORAL TABS,RX-23231,CDM,S5000,HCPCS,259,RC,33342-0116-07,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXAMETHASONE 1 MG ORAL TABS,RX-2324,CDM,S5000,HCPCS,259,RC,00054-8174-25,NDC,outpatient,1,UN,1.46,1.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-51,NDC,outpatient,1,UN,4.47,3.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-80,NDC,outpatient,1,UN,4.47,3.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,00054-8175-25,NDC,outpatient,1,UN,4.2,2.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXAMETHASONE 6 MG ORAL TABS,RX-2328,CDM,S5000,HCPCS,259,RC,00054-8183-25,NDC,outpatient,1,UN,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,S5000,HCPCS,259,RC,24208-0720-02,NDC,outpatient,5,ML,228.82,160.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-05,NDC,outpatient,5,GR,12.51,8.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-06,NDC,outpatient,5,GR,12.51,8.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,39328-0024-30,NDC,outpatient,30,GR,40.32,28.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-02,NDC,outpatient,250,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 20 % IV SOLN,RX-2359,CDM,S5000,HCPCS,250,RC,00990-7935-19,NDC,outpatient,500,ML,62.73,43.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,S5000,HCPCS,250,RC,00409-1775-10,NDC,outpatient,10,ML,57.77,40.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-16,NDC,outpatient,50,ML,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69374-0953-50,NDC,outpatient,50,ML,66.75,46.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,76329-3302-01,NDC,outpatient,50,ML,66.31,46.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-64,NDC,outpatient,50,ML,59.41,41.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-02,NDC,outpatient,50,ML,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-16,NDC,outpatient,50,ML,31.82,22.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-34,NDC,outpatient,50,ML,59.41,41.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-66,NDC,outpatient,50,ML,58.08,40.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69623-0201-39,NDC,outpatient,50,ML,93.45,65.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EFAVIRENZ 200 MG ORAL CAPS,RX-23900,CDM,S5000,HCPCS,259,RC,64980-0407-09,NDC,outpatient,1,UN,33.64,23.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,00172-3925-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MICONAZOLE NITRATE 4 % VA CREA,RX-24050,CDM,S5000,HCPCS,259,RC,63736-0442-01,NDC,outpatient,15,GR,44.73,31.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,59651-0565-01,NDC,outpatient,1,UN,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,00093-3123-01,NDC,outpatient,1,UN,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-59,NDC,outpatient,5,ML,21.65,15.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-62,NDC,outpatient,5,ML,21.65,15.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-01,NDC,outpatient,1,UN,1.75,1.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-11,NDC,outpatient,1,UN,1.75,1.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-01,NDC,outpatient,1,UN,1.8,1.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-11,NDC,outpatient,1,UN,1.8,1.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,00536-1248-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,63739-0432-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOSORBIDE MONONITRATE ER 60 MG ORAL TAB,RX-24268,CDM,S5000,HCPCS,259,RC,00904-6450-61,NDC,outpatient,1,UN,1.31,0.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TELMISARTAN 40 MG ORAL TABS,RX-24335,CDM,S5000,HCPCS,259,RC,00597-0040-37,NDC,outpatient,1,UN,19.23,13.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,S5000,HCPCS,259,RC,51672-3007-01,NDC,outpatient,10,ML,303.14,212.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,00378-4105-91,NDC,outpatient,1,UN,13.01,9.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-21,NDC,outpatient,1,UN,26.71,18.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-11,NDC,outpatient,1,UN,26.71,18.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIGOXIN 125 MCG ORAL TABS,RX-2444,CDM,S5000,HCPCS,259,RC,00904-5921-61,NDC,outpatient,1,UN,3.14,2.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-11,NDC,outpatient,1,UN,4.79,3.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,63739-0548-33,NDC,outpatient,1,UN,5.24,3.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-61,NDC,outpatient,1,UN,5.08,3.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-01,NDC,outpatient,1,UN,4.79,3.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-04,NDC,outpatient,1,UN,7.7,5.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-15,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-11,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,00904-6502-61,NDC,outpatient,1,UN,3.56,2.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-11,NDC,outpatient,1,UN,3.16,2.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-01,NDC,outpatient,1,UN,3.16,2.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,00904-6503-61,NDC,outpatient,1,UN,5.49,3.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,60505-3849-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOSORBIDE MONONITRATE ER 30 MG ORAL TB24,RX-24521,CDM,S5000,HCPCS,259,RC,00904-6449-61,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-11,NDC,outpatient,1,UN,25.83,18.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-12,NDC,outpatient,1,UN,25.83,18.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-11,NDC,outpatient,1,UN,21.38,14.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-21,NDC,outpatient,1,UN,21.38,14.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,00904-6791-04,NDC,outpatient,1,UN,21.38,14.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,S5000,HCPCS,259,RC,00574-7040-12,NDC,outpatient,1,UN,104.53,73.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,00093-0318-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-01,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-11,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIMENHYDRINATE 50 MG ORAL TABS,RX-2485,CDM,S5000,HCPCS,259,RC,00904-2051-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TACROLIMUS 0.5 MG ORAL CAPS,RX-24914,CDM,S5000,HCPCS,259,RC,00904-6623-61,NDC,outpatient,1,UN,2.82,1.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-11,NDC,outpatient,3,ML,5.32,3.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-45,NDC,outpatient,3,ML,7.12,4.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-56,NDC,outpatient,3,ML,7.12,4.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-01,NDC,outpatient,3,ML,5.32,3.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-11,NDC,outpatient,3,ML,5.47,3.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-01,NDC,outpatient,3,ML,5.47,3.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-31,NDC,outpatient,3,ML,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00487-9501-01,NDC,outpatient,3,ML,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-49,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-52,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-83,NDC,outpatient,3,ML,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-48,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-55,NDC,outpatient,3,ML,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-79,NDC,outpatient,3,ML,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-01,NDC,outpatient,3,ML,1.18,0.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-60,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,66689-0307-08,NDC,outpatient,160,ML,1111.44,778.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,99999-0002-21,NDC,outpatient,2.5,ML,69.2,48.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIPHENHYDRAMINE HCL 25 MG ORAL CAPS,RX-2509,CDM,S5000,HCPCS,259,RC,00904-7237-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-00,NDC,outpatient,5,ML,15.4,10.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-05,NDC,outpatient,5,ML,15.4,10.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,00143-9927-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,62135-0308-01,NDC,outpatient,1,UN,12.1,8.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,65862-0076-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,00406-1236-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,69315-0910-01,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,00472-0825-16,NDC,outpatient,5,ML,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,70752-0102-12,NDC,outpatient,5,ML,1.91,1.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,99999-0003-98,NDC,outpatient,5,ML,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIPYRIDAMOLE 25 MG ORAL TABS,RX-2528,CDM,S5000,HCPCS,259,RC,64980-0133-01,NDC,outpatient,1,UN,5.27,3.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-95,NDC,outpatient,1,UN,27.72,19.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-25,NDC,outpatient,1,UN,27.72,19.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DISOPYRAMIDE PHOSPHATE 100 MG ORAL CAPS,RX-2535,CDM,S5000,HCPCS,259,RC,00093-3127-01,NDC,outpatient,1,UN,5.28,3.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DISULFIRAM 250 MG ORAL TABS,RX-2540,CDM,S5000,HCPCS,259,RC,47781-0607-30,NDC,outpatient,1,UN,7.69,5.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-81,NDC,outpatient,1,UN,3.67,2.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-86,NDC,outpatient,1,UN,3.67,2.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-17,NDC,outpatient,1,UN,3.43,2.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-10,NDC,outpatient,1,UN,3.43,2.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-21,NDC,outpatient,1,UN,3.46,2.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-11,NDC,outpatient,1,UN,3.46,2.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68382-0112-14,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 0.5 MG ORAL TABS,RX-25520,CDM,S5000,HCPCS,259,RC,00904-7361-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-11,NDC,outpatient,1,UN,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-01,NDC,outpatient,1,UN,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,00904-6861-90,NDC,outpatient,1,UN,1.2,0.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-61,NDC,outpatient,1,UN,1.16,0.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-11,NDC,outpatient,1,UN,1.16,0.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7183-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-80,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,42799-0806-01,NDC,outpatient,1,UN,14.59,10.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,00006-0032-20,NDC,outpatient,1,UN,19.14,13.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,00904-7052-61,NDC,outpatient,1,UN,2.19,1.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-20,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-01,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-01,NDC,outpatient,1,UN,6.84,4.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,00378-6410-01,NDC,outpatient,1,UN,5.48,3.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-20,NDC,outpatient,1,UN,6.84,4.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-01,NDC,outpatient,1,UN,2.89,2.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,00378-3125-01,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-20,NDC,outpatient,1,UN,2.89,2.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1101-45,NDC,outpatient,85,GR,10.6,7.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,57896-0116-03,NDC,outpatient,85,GR,10.97,7.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1349-57,NDC,outpatient,85,GR,9.08,6.356,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-01,NDC,outpatient,1,UN,49.76,34.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-11,NDC,outpatient,1,UN,45.64,31.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-00,NDC,outpatient,1,UN,68.55,47.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-02,NDC,outpatient,1,UN,45.64,31.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-10,NDC,outpatient,1,UN,68.55,47.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-10,NDC,outpatient,1,UN,49.76,34.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-01,NDC,outpatient,1,UN,107.52,75.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-10,NDC,outpatient,1,UN,107.52,75.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,00904-6474-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-51,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-80,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00904-0430-06,NDC,outpatient,1,UN,5.29,3.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-21,NDC,outpatient,1,UN,4.84,3.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00143-2112-50,NDC,outpatient,1,UN,1.07,0.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-11,NDC,outpatient,1,UN,4.84,3.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-11,NDC,outpatient,1,UN,4.16,2.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-01,NDC,outpatient,1,UN,4.16,2.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,64380-0799-01,NDC,outpatient,1,UN,8.24,5.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,31722-0632-31,NDC,outpatient,1,UN,4.28,2.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-11,NDC,outpatient,1,UN,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,27241-0049-10,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-21,NDC,outpatient,1,UN,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EXEMESTANE 25 MG ORAL TABS,RX-26551,CDM,S5000,HCPCS,259,RC,59762-2858-01,NDC,outpatient,1,UN,6.65,4.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,65862-0246-08,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,00904-7124-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MOXIFLOXACIN HCL 400 MG ORAL TABS,RX-26854,CDM,S5000,HCPCS,259,RC,65862-0603-30,NDC,outpatient,1,UN,13.67,9.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,16729-0490-12,NDC,outpatient,1,UN,6.58,4.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,69452-0131-17,NDC,outpatient,1,UN,2.23,1.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,72205-0039-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,00904-6682-08,NDC,outpatient,1,UN,13.18,9.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,42291-0412-60,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,69452-0132-17,NDC,outpatient,1,UN,2.23,1.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,42291-0413-60,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,00904-6683-08,NDC,outpatient,1,UN,13.31,9.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TERBINAFINE HCL 1 % EX CREA,RX-27023,CDM,S5000,HCPCS,259,RC,51672-2080-01,NDC,outpatient,15,GR,24.57,17.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,S5000,HCPCS,259,RC,11980-0174-05,NDC,outpatient,5,ML,659.54,461.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-11,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-01,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHARCOAL ACTIVATED ORAL LIQD,RX-27099,CDM,S5000,HCPCS,259,RC,66689-0202-04,NDC,outpatient,120,ML,82.77,57.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISEDRONATE SODIUM 5 MG ORAL TABS,RX-27112,CDM,S5000,HCPCS,259,RC,33342-0107-07,NDC,outpatient,1,UN,11.13,7.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,59651-0018-90,NDC,outpatient,1,UN,1.7,1.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,47335-0539-81,NDC,outpatient,1,UN,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-1210-01,NDC,outpatient,454,GR,8.09,5.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,49580-0394-04,NDC,outpatient,1814,GR,16.15,11.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-0038-01,NDC,outpatient,454,GR,8.09,5.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-10,NDC,outpatient,10,ML,39.03,27.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-02,NDC,outpatient,2,ML,34.38,24.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE ER 100 MG ORAL CP24,RX-27418,CDM,S5000,HCPCS,259,RC,52244-0100-10,NDC,outpatient,1,UN,14.48,10.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,S5000,HCPCS,250,RC,63323-0113-10,NDC,outpatient,1,UN,686.14,480.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,S5000,HCPCS,259,RC,55566-2800-01,NDC,outpatient,1,UN,2100.63,1470.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-16,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-93,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-16,NDC,outpatient,1,UN,2.2,1.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-93,NDC,outpatient,1,UN,2.2,1.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-01,NDC,outpatient,1,UN,217.89,152.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-30,NDC,outpatient,1,UN,217.89,152.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-93,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,43598-0894-30,NDC,outpatient,1,UN,9.32,6.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-16,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-93,NDC,outpatient,1,UN,3.17,2.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-16,NDC,outpatient,1,UN,3.17,2.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,00603-3581-21,NDC,outpatient,1,UN,1.73,1.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,68462-0233-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,13668-0132-01,NDC,outpatient,1,UN,1.96,1.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,63824-0056-34,NDC,outpatient,1,UN,1.93,1.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,00536-1161-37,NDC,outpatient,1,UN,1.77,1.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68382-0106-01,NDC,outpatient,1,UN,1.55,1.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-11,NDC,outpatient,1,UN,3.24,2.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-01,NDC,outpatient,1,UN,3.24,2.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-13,NDC,outpatient,1,UN,7.06,4.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-11,NDC,outpatient,1,UN,7.06,4.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE ER 300 MG ORAL CP12,RX-27633,CDM,S5000,HCPCS,259,RC,66993-0409-32,NDC,outpatient,1,UN,5.66,3.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE ER 100 MG ORAL TB12,RX-27634,CDM,S5000,HCPCS,259,RC,51672-4123-01,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE ER 400 MG ORAL TB12,RX-27636,CDM,S5000,HCPCS,259,RC,51672-4125-01,NDC,outpatient,1,UN,2.24,1.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,49884-0007-02,NDC,outpatient,1,UN,22.19,15.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,68462-0405-60,NDC,outpatient,1,UN,2.36,1.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-01,NDC,outpatient,1,UN,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-11,NDC,outpatient,1,UN,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-21,NDC,outpatient,1,UN,11.24,7.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,62175-0262-37,NDC,outpatient,1,UN,9.51,6.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-11,NDC,outpatient,1,UN,11.24,7.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,S5000,HCPCS,259,RC,17238-0900-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,S5000,HCPCS,259,RC,41167-0057-24,NDC,outpatient,141,GR,30.75,21.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,RX-27770,CDM,S5000,HCPCS,259,RC,24208-0342-05,NDC,outpatient,5,ML,655.13,458.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-15,NDC,outpatient,1,UN,2.24,1.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-11,NDC,outpatient,1,UN,2.24,1.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-02,NDC,outpatient,250,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-04,NDC,outpatient,500,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-48,NDC,outpatient,100,ML,22.69,15.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00487-4301-10,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-38,NDC,outpatient,100,ML,22.17,15.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-41,NDC,outpatient,50,ML,22.94,16.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,,,outpatient,500,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00409-7101-67,NDC,outpatient,100,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-01,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-11,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,00904-7077-61,NDC,outpatient,1,UN,1.54,1.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-01,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-11,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,S5000,HCPCS,259,RC,43598-0446-74,NDC,outpatient,1,UN,4.78,3.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,S5000,HCPCS,259,RC,43598-0447-74,NDC,outpatient,1,UN,5.28,3.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-28,NDC,outpatient,1,UN,5.25,3.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-74,NDC,outpatient,1,UN,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-88,NDC,outpatient,1,UN,7.5,5.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-33,NDC,outpatient,1,UN,7.5,5.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,99999-0002-05,NDC,outpatient,15,ML,60.48,42.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,62135-0712-42,NDC,outpatient,5,ML,20.16,14.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,00054-3500-49,NDC,outpatient,5,ML,2.23,1.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,72888-0125-26,NDC,outpatient,5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-11,NDC,outpatient,1,UN,17.49,12.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-47,NDC,outpatient,1,UN,17.49,12.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-98,NDC,outpatient,1,UN,37.78,26.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-47,NDC,outpatient,1,UN,25.49,17.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-16,NDC,outpatient,1,UN,37.78,26.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-11,NDC,outpatient,1,UN,25.49,17.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-11,NDC,outpatient,1,UN,37.66,26.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-47,NDC,outpatient,1,UN,37.66,26.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-16,NDC,outpatient,1,UN,93.74,65.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-98,NDC,outpatient,1,UN,93.74,65.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-10,NDC,outpatient,1,UN,3.99,2.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-30,NDC,outpatient,1,UN,4.71,3.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML ORAL SUSP,RX-27999,CDM,S5000,HCPCS,259,RC,46287-0006-60,NDC,outpatient,60,ML,91.85,64.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,16714-0601-02,NDC,outpatient,2.5,ML,10.37,7.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,99999-0003-51,NDC,outpatient,2.5,ML,10.37,7.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FE FUMARATE-B12-VIT C-FA-IFC ORAL CAPS,RX-28030,CDM,S5000,HCPCS,259,RC,51991-0635-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-01,NDC,outpatient,78,GR,22.91,16.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-02,NDC,outpatient,56,GR,17.7,12.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN BUF(CACARB-MGCARB-MGO) 325 MG ORAL TABS,RX-28122,CDM,S5000,HCPCS,259,RC,00904-2015-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-79,NDC,outpatient,1,UN,3.06,2.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,60505-3275-00,NDC,outpatient,1,UN,1.9,1.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-65,NDC,outpatient,1,UN,2.89,2.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,33342-0083-07,NDC,outpatient,1,UN,3.81,2.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-81,NDC,outpatient,1,UN,3.06,2.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-19,NDC,outpatient,1,UN,2.89,2.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-55,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-52,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,00904-6553-04,NDC,outpatient,1,UN,7.73,5.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-33,NDC,outpatient,1,UN,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-84,NDC,outpatient,1,UN,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,59762-1308-04,NDC,outpatient,150,ML,1694.12,1185.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,99999-0002-85,NDC,outpatient,30,ML,340.43,238.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,S5000,HCPCS,259,RC,63323-0877-15,NDC,outpatient,1,UN,686.24,480.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAPS,RX-28278,CDM,S5000,HCPCS,259,RC,00904-7107-61,NDC,outpatient,1,UN,10.27,7.189,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE TARTRATE 3 MG ORAL CAPS,RX-28279,CDM,S5000,HCPCS,259,RC,55111-0353-60,NDC,outpatient,1,UN,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN GLARGINE 100 UNIT/ML SC SOLN,RX-28282,CDM,S5000,HCPCS,259,RC,00088-2220-33,NDC,outpatient,10,ML,252.19,176.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-95,NDC,outpatient,1,UN,13.08,9.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-25,NDC,outpatient,1,UN,13.08,9.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-62,NDC,outpatient,1,UN,2,1.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-23,NDC,outpatient,1,UN,2,1.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-99,NDC,outpatient,1,UN,65.95,46.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-16,NDC,outpatient,1,UN,65.95,46.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-16,NDC,outpatient,1,UN,65.26,45.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-99,NDC,outpatient,1,UN,65.26,45.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-01,NDC,outpatient,1,UN,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-11,NDC,outpatient,1,UN,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,13811-0706-10,NDC,outpatient,1,UN,3.22,2.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,50458-0585-01,NDC,outpatient,1,UN,53.04,37.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00186-1988-04,NDC,outpatient,2,ML,35.8,25.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00487-9601-01,NDC,outpatient,2,ML,17.76,12.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-05,NDC,outpatient,2,ML,5.21,3.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-53,NDC,outpatient,2,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-86,NDC,outpatient,2,ML,8.61,6.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00487-9701-01,NDC,outpatient,2,ML,14.93,10.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-30,NDC,outpatient,2,ML,5.21,3.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-45,NDC,outpatient,2,ML,39.45,27.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-73,NDC,outpatient,2,ML,39.45,27.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,47335-0632-49,NDC,outpatient,1,ML,6.14,4.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-32,NDC,outpatient,2,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-87,NDC,outpatient,2,ML,8.61,6.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-16,NDC,outpatient,453.6,GR,58.59,41.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,08080-4302-01,NDC,outpatient,30,ML,5.88,4.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-21,NDC,outpatient,28.35,GR,7.2,5.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2311-00,NDC,outpatient,52.5,GR,7.25,5.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2335-00,NDC,outpatient,390,GR,19.1,13.37,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,53329-0993-04,NDC,outpatient,113,GR,5.26,3.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,38779-3068-00,NDC,outpatient,30,GR,75.03,52.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,24208-0635-62,NDC,outpatient,10,ML,221.08,154.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,61314-0645-11,NDC,outpatient,10,ML,217.88,152.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLYCERIN LIQD,RX-28815,CDM,S5000,HCPCS,259,RC,00395-1031-96,NDC,outpatient,177,ML,23.63,16.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP,RX-28836,CDM,S5000,HCPCS,259,RC,00121-0431-30,NDC,outpatient,30,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-19,NDC,outpatient,1,UN,1.84,1.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-65,NDC,outpatient,1,UN,1.84,1.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-15,NDC,outpatient,1,UN,46.19,32.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-61,NDC,outpatient,1,UN,46.19,32.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,RX-28844,CDM,S5000,HCPCS,259,RC,00172-7313-20,NDC,outpatient,50,ML,396.5,277.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN 2 % EX SOLN,RX-2887,CDM,S5000,HCPCS,259,RC,45802-0038-46,NDC,outpatient,60,ML,71.56,50.092,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-50,NDC,outpatient,1,GR,31.37,21.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,24208-0910-19,NDC,outpatient,1,GR,31.03,21.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,48102-0057-11,NDC,outpatient,1,GR,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-11,NDC,outpatient,1,GR,31.37,21.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-11,NDC,outpatient,1,UN,4.25,2.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-59,NDC,outpatient,1,UN,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-01,NDC,outpatient,1,UN,4.25,2.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-61,NDC,outpatient,1,UN,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-23,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-62,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,13668-0586-30,NDC,outpatient,1,UN,21.71,15.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,24338-0122-03,NDC,outpatient,1,UN,24.57,17.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NA HYALUR & NA CHOND-NA HYALUR 0.4-0.35 ML IO KIT,RX-28916,CDM,S5000,HCPCS,250,RC,08065-1831-35,NDC,outpatient,0.75,ML,867.31,607.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOFLOXACIN 750 MG ORAL TABS,RX-28964,CDM,S5000,HCPCS,259,RC,00904-6353-61,NDC,outpatient,1,UN,2.17,1.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,99999-0002-77,NDC,outpatient,5,ML,50.87,35.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,24338-0134-02,NDC,outpatient,100,ML,1005.7,703.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,75834-0295-01,NDC,outpatient,100,ML,494.4,346.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,51224-0007-50,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,70010-0491-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALENDRONATE SODIUM 70 MG ORAL TABS,RX-29048,CDM,S5000,HCPCS,259,RC,16714-0633-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALENDRONATE SODIUM 35 MG ORAL TABS,RX-29072,CDM,S5000,HCPCS,259,RC,16714-0632-01,NDC,outpatient,1,UN,5.43,3.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-06,NDC,outpatient,6,ML,15.62,10.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,99999-0003-42,NDC,outpatient,6,ML,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-16,NDC,outpatient,470,ML,144.32,101.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-06,NDC,outpatient,6,ML,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-40,NDC,outpatient,6,ML,15.62,10.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-07,NDC,outpatient,470,ML,154.78,108.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-06,NDC,outpatient,6,ML,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-90,NDC,outpatient,473,ML,168.39,117.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-30,NDC,outpatient,1,UN,1.44,1.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-01,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-11,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,68682-0993-98,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,00904-7218-61,NDC,outpatient,1,UN,1.28,0.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,62037-0598-90,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-11,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,00904-7219-61,NDC,outpatient,1,UN,1.59,1.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-11,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-01,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-01,NDC,outpatient,1,UN,6.23,4.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-11,NDC,outpatient,1,UN,6.23,4.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,24979-0029-07,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCOSANOL 10 % EX CREA,RX-29287,CDM,S5000,HCPCS,259,RC,00135-0300-01,NDC,outpatient,2,GR,72.76,50.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,00054-0079-28,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-13,NDC,outpatient,1,UN,5.8,4.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-11,NDC,outpatient,1,UN,5.8,4.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,65649-0101-02,NDC,outpatient,1,UN,26.86,18.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,72789-0149-69,NDC,outpatient,1,UN,1.89,1.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,60505-2575-07,NDC,outpatient,1,UN,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,16714-0496-01,NDC,outpatient,15,GR,55.61,38.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,00168-0258-15,NDC,outpatient,15,GR,71.29,49.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-21,NDC,outpatient,1,UN,7.98,5.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-11,NDC,outpatient,1,UN,7.98,5.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIRTAZAPINE 15 MG ORAL TBDP,RX-29531,CDM,S5000,HCPCS,259,RC,65862-0021-06,NDC,outpatient,1,UN,1.96,1.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIPRASIDONE HCL 20 MG ORAL CAPS,RX-29778,CDM,S5000,HCPCS,259,RC,00904-6269-08,NDC,outpatient,1,UN,11.99,8.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-11,NDC,outpatient,1,UN,7.81,5.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-12,NDC,outpatient,1,UN,7.96,5.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-11,NDC,outpatient,1,UN,7.96,5.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-09,NDC,outpatient,1,UN,7.81,5.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,00781-2168-60,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-09,NDC,outpatient,1,UN,7.81,5.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-11,NDC,outpatient,1,UN,7.81,5.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,70436-0004-06,NDC,outpatient,1,UN,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-11,NDC,outpatient,1,UN,14.03,9.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-21,NDC,outpatient,1,UN,14.03,9.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-06,NDC,outpatient,1,UN,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,45963-0709-11,NDC,outpatient,1,UN,1.28,0.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,50742-0615-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-01,NDC,outpatient,1,UN,2.11,1.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-20,NDC,outpatient,1,UN,2.11,1.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-61,NDC,outpatient,1,UN,2.19,1.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EYE STREAM OP SOLN,RX-2999,CDM,S5000,HCPCS,259,RC,00065-0530-01,NDC,outpatient,30,ML,81.97,57.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-20,NDC,outpatient,1,UN,1.9,1.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,00904-6323-61,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,68382-0565-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,50742-0616-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-01,NDC,outpatient,1,UN,1.9,1.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,00904-6324-61,NDC,outpatient,1,UN,2.66,1.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-15,NDC,outpatient,1,UN,2.35,1.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-01,NDC,outpatient,1,UN,5.81,4.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-11,NDC,outpatient,1,UN,2.35,1.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-03,NDC,outpatient,1,UN,5.81,4.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-01,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-11,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,63739-0357-33,NDC,outpatient,1,UN,93.6,65.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-25,NDC,outpatient,1,UN,121.31,84.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-95,NDC,outpatient,1,UN,121.31,84.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CITALOPRAM HYDROBROMIDE 10 MG ORAL TABS,RX-30264,CDM,S5000,HCPCS,259,RC,00904-6084-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,00078-0357-52,NDC,outpatient,5,ML,39.3,27.51,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,99999-0002-25,NDC,outpatient,5,ML,33.09,23.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-59,NDC,outpatient,5,ML,23.66,16.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-62,NDC,outpatient,5,ML,23.66,16.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MELATONIN 5 MG SL SUBL,RX-30511,CDM,S5000,HCPCS,259,RC,54629-0615-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7590-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,20555-0021-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7591-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-20,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,00904-7041-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-01,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,16714-0576-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,55111-0729-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,00904-6572-61,NDC,outpatient,1,UN,1.71,1.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-01,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-20,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,00143-9853-75,NDC,outpatient,75,ML,63.42,44.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,99999-0002-82,NDC,outpatient,5,ML,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-11,NDC,outpatient,1,UN,4.62,3.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,31722-0153-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,33342-0064-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-01,NDC,outpatient,1,UN,4.62,3.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,00574-9855-10,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,65162-0778-10,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,00487-0301-01,NDC,outpatient,3,ML,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,76204-0010-55,NDC,outpatient,3,ML,1.98,1.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-25,NDC,outpatient,3,ML,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-01,NDC,outpatient,3,ML,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,00228-3059-11,NDC,outpatient,1,UN,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,70010-0030-01,NDC,outpatient,1,UN,3.45,2.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,64850-0511-01,NDC,outpatient,1,UN,2,1.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,54295-0312-18,NDC,outpatient,226.8,GR,419.86,293.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,81542-0201-08,NDC,outpatient,226.8,GR,454.17,317.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TABS,RX-31684,CDM,S5000,HCPCS,259,RC,61958-0401-01,NDC,outpatient,1,UN,180.36,126.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,00093-0262-15,NDC,outpatient,15,GR,162.14,113.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,51672-1386-01,NDC,outpatient,15,GR,35.32,24.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,S5000,HCPCS,259,RC,51672-1264-01,NDC,outpatient,15,GR,55.01,38.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,S5000,HCPCS,259,RC,51672-1273-02,NDC,outpatient,20,ML,137.87,96.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,S5000,HCPCS,259,RC,60758-0880-05,NDC,outpatient,5,ML,308.83,216.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUPHENAZINE HCL 1 MG ORAL TABS,RX-3218,CDM,S5000,HCPCS,259,RC,00527-1788-01,NDC,outpatient,1,UN,6.6,4.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,00527-1789-01,NDC,outpatient,1,UN,10.2,7.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,70954-0274-10,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,00527-1790-01,NDC,outpatient,1,UN,13.8,9.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,69238-1680-01,NDC,outpatient,1,UN,6.45,4.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,39822-1100-01,NDC,outpatient,0.2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,63323-0184-10,NDC,outpatient,0.2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,00904-7224-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,00781-1061-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,65862-0676-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALPRAZOLAM 0.5 MG ORAL TABS,RX-325,CDM,S5000,HCPCS,259,RC,00781-1077-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAROXETINE HCL ER 12.5 MG ORAL TB24,RX-32631,CDM,S5000,HCPCS,259,RC,62175-0470-32,NDC,outpatient,1,UN,4.97,3.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPHENIDATE HCL ER (OSM) 27 MG ORAL TBCR,RX-32654,CDM,S5000,HCPCS,259,RC,13811-0707-10,NDC,outpatient,1,UN,3.33,2.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,33342-0179-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,00713-0861-30,NDC,outpatient,1,UN,39.98,27.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,68462-0437-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISEDRONATE SODIUM 35 MG ORAL TABS,RX-32895,CDM,S5000,HCPCS,259,RC,33342-0109-50,NDC,outpatient,1,UN,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-62,NDC,outpatient,4,ML,7.04,4.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-59,NDC,outpatient,4,ML,7.04,4.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-62,NDC,outpatient,5,ML,7.04,4.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-59,NDC,outpatient,5,ML,7.04,4.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00054-8297-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00904-7177-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,00054-8301-25,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMPHETAMINE-DEXTROAMPHET ER 5 MG ORAL CP24,RX-33005,CDM,S5000,HCPCS,259,RC,54092-0381-01,NDC,outpatient,1,UN,29.29,20.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VORICONAZOLE 200 MG ORAL TABS,RX-33009,CDM,S5000,HCPCS,259,RC,00904-7024-04,NDC,outpatient,1,UN,43.81,30.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TABS,RX-33227,CDM,S5000,HCPCS,259,RC,00781-1831-01,NDC,outpatient,1,UN,1.59,1.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,42571-0162-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-01,NDC,outpatient,1,UN,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-20,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,00143-9249-20,NDC,outpatient,1,UN,5.26,3.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,00904-6426-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-11,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-01,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-11,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-21,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,31722-0151-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-11,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-01,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METAXALONE 800 MG ORAL TABS,RX-33963,CDM,S5000,HCPCS,259,RC,00527-1435-01,NDC,outpatient,1,UN,2.54,1.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DUTASTERIDE 0.5 MG ORAL CAPS,RX-34089,CDM,S5000,HCPCS,259,RC,42806-0549-09,NDC,outpatient,1,UN,1.7,1.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,51660-0200-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-21,NDC,outpatient,1,UN,18.75,13.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,00904-7103-04,NDC,outpatient,1,UN,18.36,12.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-11,NDC,outpatient,1,UN,18.75,13.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,S5000,HCPCS,259,RC,45802-0056-35,NDC,outpatient,15,GR,170.02,119.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,S5000,HCPCS,259,RC,45802-0046-35,NDC,outpatient,15,GR,132.44,92.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,24208-0580-60,NDC,outpatient,5,ML,23.41,16.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,61314-0633-05,NDC,outpatient,5,ML,21.99,15.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-11,NDC,outpatient,1,UN,22.5,15.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-01,NDC,outpatient,1,UN,22.5,15.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,27241-0054-03,NDC,outpatient,1,UN,2.88,2.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-11,NDC,outpatient,1,UN,27.24,19.068,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-21,NDC,outpatient,1,UN,27.24,19.068,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,63739-0078-33,NDC,outpatient,1,UN,22.38,15.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-11,NDC,outpatient,1,UN,2.75,1.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-01,NDC,outpatient,1,UN,2.75,1.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,35573-0415-30,NDC,outpatient,1,UN,14,9.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,55111-0519-30,NDC,outpatient,1,UN,7.25,5.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,31722-0714-30,NDC,outpatient,1,UN,8.16,5.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,68462-0265-30,NDC,outpatient,1,UN,4.5,3.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,16714-0757-01,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,64980-0375-03,NDC,outpatient,1,UN,7.25,5.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,00093-3545-56,NDC,outpatient,1,UN,17.9,12.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-25,NDC,outpatient,1,UN,14.68,10.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,68462-0268-30,NDC,outpatient,1,UN,2.91,2.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-95,NDC,outpatient,1,UN,14.68,10.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-62,NDC,outpatient,1,UN,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-23,NDC,outpatient,1,UN,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-11,NDC,outpatient,1,UN,6.96,4.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-21,NDC,outpatient,1,UN,6.96,4.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,42858-0502-03,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-21,NDC,outpatient,1,UN,11.98,8.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-11,NDC,outpatient,1,UN,11.98,8.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,00054-0188-13,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,65162-0416-03,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-11,NDC,outpatient,1,UN,14.96,10.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,42858-0602-03,NDC,outpatient,1,UN,27,18.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-15,NDC,outpatient,1,UN,14.96,10.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,24208-0631-10,NDC,outpatient,10,ML,205.06,143.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,61314-0646-10,NDC,outpatient,10,ML,188.28,131.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-01,NDC,outpatient,1,UN,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,00904-6779-61,NDC,outpatient,1,UN,3.97,2.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-11,NDC,outpatient,1,UN,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,16714-0990-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-11,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-01,NDC,outpatient,1,UN,5.36,3.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-11,NDC,outpatient,1,UN,5.36,3.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,00904-6780-61,NDC,outpatient,1,UN,3.57,2.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-15,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,S5000,HCPCS,259,RC,00023-9163-30,NDC,outpatient,1,UN,44.22,30.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,99999-0002-48,NDC,outpatient,30,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,00536-0091-85,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GRISEOFULVIN ULTRAMICROSIZE 250 MG ORAL TABS,RX-3536,CDM,S5000,HCPCS,259,RC,00115-1725-01,NDC,outpatient,1,UN,20.98,14.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-01,NDC,outpatient,1,UN,349.43,244.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-08,NDC,outpatient,1,UN,10.21,7.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-08,NDC,outpatient,1,UN,349.43,244.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-01,NDC,outpatient,1,UN,10.21,7.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-52,NDC,outpatient,1,UN,2.41,1.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-55,NDC,outpatient,1,UN,2.41,1.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-55,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-52,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,00832-1410-03,NDC,outpatient,3,ML,113.88,79.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,72266-0158-01,NDC,outpatient,3,ML,45.03,31.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,70010-0492-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,62756-0143-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,67877-0414-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00832-1530-11,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00378-0214-01,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-01,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-20,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,54838-0501-15,NDC,outpatient,0.5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,99999-0003-09,NDC,outpatient,0.5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-89,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-01,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,63739-0972-10,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-01,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-89,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00832-5325-11,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATAZANAVIR SULFATE 150 MG ORAL CAPS,RX-36149,CDM,S5000,HCPCS,259,RC,42385-0920-60,NDC,outpatient,1,UN,11.33,7.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATAZANAVIR SULFATE 200 MG ORAL CAPS,RX-36150,CDM,S5000,HCPCS,259,RC,65862-0712-60,NDC,outpatient,1,UN,13.22,9.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREMASOL 10 % IV SOLN,RX-36160,CDM,S5000,HCPCS,250,RC,00338-1130-03,NDC,outpatient,500,ML,98.33,68.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EMTRICITABINE 200 MG ORAL CAPS,RX-36252,CDM,S5000,HCPCS,259,RC,61958-0601-01,NDC,outpatient,1,UN,77.2,54.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-15,NDC,outpatient,1,UN,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-11,NDC,outpatient,1,UN,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-01,NDC,outpatient,1,UN,15.64,10.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-11,NDC,outpatient,1,UN,15.64,10.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,43598-0326-75,NDC,outpatient,7.5,ML,438.69,307.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,16714-0628-01,NDC,outpatient,7.5,ML,422.83,295.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,62756-0427-90,NDC,outpatient,7.5,ML,336.96,235.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-40,NDC,outpatient,5,ML,12.02,8.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-05,NDC,outpatient,5,ML,9.93,6.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-40,NDC,outpatient,5,ML,9.93,6.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-67,NDC,outpatient,5,ML,12.02,8.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROSUVASTATIN CALCIUM 5 MG ORAL TABS,RX-36612,CDM,S5000,HCPCS,259,RC,00904-6778-61,NDC,outpatient,1,UN,2.9,2.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETOROLAC TROMETHAMINE 0.4 % OP SOLN,RX-36631,CDM,S5000,HCPCS,259,RC,60758-0773-05,NDC,outpatient,5,ML,248.94,174.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-04,NDC,outpatient,1,UN,5.27,3.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-61,NDC,outpatient,1,UN,6.35,4.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,16729-0443-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-10,NDC,outpatient,10,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-01,NDC,outpatient,10,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-00,NDC,outpatient,10,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,99999-0001-96,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-10,NDC,outpatient,10,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,29033-0001-01,NDC,outpatient,1,UN,5.44,3.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,42858-0701-01,NDC,outpatient,1,UN,3.89,2.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,49348-0991-36,NDC,outpatient,177,ML,7.88,5.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,78112-0011-03,NDC,outpatient,177,ML,17.33,12.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,00904-6305-21,NDC,outpatient,177,ML,7.09,4.963,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,29300-0155-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,57237-0114-90,NDC,outpatient,1,UN,2,1.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,59762-1710-02,NDC,outpatient,1,UN,5.59,3.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-11,NDC,outpatient,1,UN,18.55,12.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-21,NDC,outpatient,1,UN,18.55,12.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,51991-0877-33,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZONISAMIDE 25 MG ORAL CAPS,RX-36987,CDM,S5000,HCPCS,259,RC,68462-0128-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,31722-0520-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-01,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,63739-0327-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,23155-0833-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-20,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,00536-3445-08,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,57896-0621-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-45,NDC,outpatient,1,UN,1.42,0.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00832-1112-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-57,NDC,outpatient,1,UN,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-44,NDC,outpatient,1,UN,1.42,0.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00904-6505-61,NDC,outpatient,1,UN,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-11,NDC,outpatient,1,UN,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,00536-1277-80,NDC,outpatient,28,GR,5.24,3.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,49348-0521-72,NDC,outpatient,28.4,GR,6.32,4.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00394-0859-32,NDC,outpatient,114,ML,22.83,15.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00096-0732-04,NDC,outpatient,120,ML,56.61,39.627,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,S5000,HCPCS,259,RC,00168-0020-31,NDC,outpatient,28.35,GR,18.05,12.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-11,NDC,outpatient,1,UN,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-01,NDC,outpatient,1,UN,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,59762-0074-01,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,00574-7090-12,NDC,outpatient,1,UN,5.54,3.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,10135-0751-12,NDC,outpatient,1,UN,7.8,5.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-63,NDC,outpatient,1,UN,2.84,1.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-60,NDC,outpatient,1,UN,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-89,NDC,outpatient,1,UN,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-95,NDC,outpatient,1,UN,3.48,2.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-98,NDC,outpatient,1,UN,3.48,2.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-65,NDC,outpatient,1,UN,2.84,1.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-11,NDC,outpatient,1,UN,7.06,4.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-13,NDC,outpatient,1,UN,7.06,4.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BSS IO SOLN,RX-37579,CDM,S5000,HCPCS,259,RC,00065-0795-15,NDC,outpatient,15,ML,24.7,17.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,00406-3243-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-11,NDC,outpatient,1,UN,1.27,0.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-01,NDC,outpatient,1,UN,1.27,0.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-01,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,00406-3244-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,42858-0234-01,NDC,outpatient,1,UN,17.03,11.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-01,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-11,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,00378-0018-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,59762-0016-01,NDC,outpatient,100,ML,170.44,119.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,23155-0603-51,NDC,outpatient,100,ML,170.44,119.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,99999-0002-90,NDC,outpatient,10,ML,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-11,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-21,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-11,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-01,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,63824-0008-50,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-01,NDC,outpatient,1,UN,2.76,1.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,00904-6718-39,NDC,outpatient,1,UN,2.32,1.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-11,NDC,outpatient,1,UN,2.76,1.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,54838-0502-80,NDC,outpatient,5,ML,2.88,2.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,62135-0750-47,NDC,outpatient,5,ML,21.74,15.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,99999-0002-50,NDC,outpatient,5,ML,1.16,0.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYZINE HCL 10 MG ORAL TABS,RX-3772,CDM,S5000,HCPCS,259,RC,63739-0483-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,00904-6617-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,63739-0486-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TALC 5 G PL SUSR,RX-37812,CDM,S5000,HCPCS,259,RC,63256-0200-05,NDC,outpatient,1,UN,458.35,320.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,55513-0073-30,NDC,outpatient,1,UN,75.45,52.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,70436-0007-04,NDC,outpatient,1,UN,1.94,1.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-11,NDC,outpatient,1,UN,64.87,45.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,00904-7067-04,NDC,outpatient,1,UN,76.53,53.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-21,NDC,outpatient,1,UN,64.87,45.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ORPHENADRINE CITRATE ER 100 MG ORAL TB12,RX-38213,CDM,S5000,HCPCS,259,RC,43386-0480-24,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,00228-2778-11,NDC,outpatient,1,UN,6.75,4.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,42291-0522-01,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,62559-0530-01,NDC,outpatient,1,UN,2.1,1.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00228-2779-11,NDC,outpatient,1,UN,8.57,5.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00527-4117-37,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,00228-2780-11,NDC,outpatient,1,UN,10.29,7.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,42291-0524-01,NDC,outpatient,1,UN,2.42,1.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-00,NDC,outpatient,30,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-30,NDC,outpatient,30,ML,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-65,NDC,outpatient,15,ML,1.01,0.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,99999-0001-83,NDC,outpatient,30,ML,2.16,1.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-30,NDC,outpatient,30,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-06,NDC,outpatient,1,UN,12.96,9.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-64,NDC,outpatient,1,UN,12.96,9.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 200 MG ORAL TABS,RX-3841,CDM,S5000,HCPCS,259,RC,00904-7914-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 600 MG ORAL TABS,RX-3844,CDM,S5000,HCPCS,259,RC,00904-5854-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-09,NDC,outpatient,1,ML,15.58,10.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-01,NDC,outpatient,4,ML,53.96,37.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IBUPROFEN 800 MG ORAL TABS,RX-3845,CDM,S5000,HCPCS,259,RC,00904-5855-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUOXETINE HCL 20 MG/5ML ORAL SOLN,RX-38488,CDM,S5000,HCPCS,259,RC,00121-4721-05,NDC,outpatient,5,ML,14.38,10.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IMIPRAMINE HCL 10 MG ORAL TABS,RX-3860,CDM,S5000,HCPCS,259,RC,69584-0425-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IMIPRAMINE HCL 25 MG ORAL TABS,RX-3861,CDM,S5000,HCPCS,259,RC,69584-0426-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,S5000,HCPCS,259,RC,24208-0780-55,NDC,outpatient,3.5,GR,57.59,40.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,00228-2571-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,62559-0511-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SELENIUM SULFIDE 1 % EX SHAM,RX-38961,CDM,S5000,HCPCS,259,RC,00536-1995-53,NDC,outpatient,207,ML,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PEG 3350-KCL-NABCB-NACL-NASULF 240 G ORAL SOLR,RX-38965,CDM,S5000,HCPCS,259,RC,43386-0060-19,NDC,outpatient,4000,ML,53.4,37.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-15,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-11,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,S5000,HCPCS,259,RC,69344-0102-33,NDC,outpatient,1,UN,1095.8,767.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAXIMIN 200 MG ORAL TABS,RX-39063,CDM,S5000,HCPCS,259,RC,65649-0301-03,NDC,outpatient,1,UN,43.55,30.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMILORIDE HCL 5 MG ORAL TABS,RX-391,CDM,S5000,HCPCS,259,RC,00574-0292-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,00832-0465-15,NDC,outpatient,15,GR,37.52,26.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68382-0370-01,NDC,outpatient,15,GR,31.18,21.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,16714-0769-01,NDC,outpatient,15,GR,25.04,17.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68308-0152-15,NDC,outpatient,15,GR,27.84,19.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,69315-0306-15,NDC,outpatient,15,GR,24.5,17.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EMTRICITABINE-TENOFOVIR DF 200-300 MG ORAL TABS,RX-39255,CDM,S5000,HCPCS,259,RC,61958-0701-01,NDC,outpatient,1,UN,265.08,185.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,00904-7043-04,NDC,outpatient,1,UN,3.3,2.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-21,NDC,outpatient,1,UN,3.39,2.373,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-11,NDC,outpatient,1,UN,3.39,2.373,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-01,NDC,outpatient,1,UN,3.41,2.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,57237-0018-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,00904-7044-61,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-11,NDC,outpatient,1,UN,3.41,2.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-93,NDC,outpatient,1,UN,20.14,14.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-31,NDC,outpatient,1,UN,20.14,14.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,65862-0219-60,NDC,outpatient,60,ML,88.92,62.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,68180-0723-04,NDC,outpatient,60,ML,87.31,61.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,99999-0002-80,NDC,outpatient,6,ML,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE ER 500 MG ORAL CPCR,RX-39575,CDM,S5000,HCPCS,259,RC,54092-0191-12,NDC,outpatient,1,UN,24.97,17.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,48433-0230-15,NDC,outpatient,14,ML,132.64,92.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,51552-0019-44,NDC,outpatient,14,ML,5.44,3.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-95,NDC,outpatient,1,UN,6.9,4.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-25,NDC,outpatient,1,UN,6.9,4.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-01,NDC,outpatient,5,ML,12.98,9.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-01,NDC,outpatient,5,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-10,NDC,outpatient,5,ML,12.98,9.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-10,NDC,outpatient,5,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,63323-0424-05,NDC,outpatient,5,ML,15.68,10.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,00527-1948-68,NDC,outpatient,10,ML,85.98,60.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,99999-0002-53,NDC,outpatient,10,ML,37.07,25.949,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-45,NDC,outpatient,1,UN,49.37,34.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-90,NDC,outpatient,1,UN,49.37,34.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-42,NDC,outpatient,1,UN,24.73,17.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-52,NDC,outpatient,1,UN,24.73,17.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-20,NDC,outpatient,1,UN,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-01,NDC,outpatient,1,UN,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,60687-0629-21,NDC,outpatient,1,UN,4.19,2.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,51079-0608-20,NDC,outpatient,1,UN,10.74,7.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-01,NDC,outpatient,10,ML,19.54,13.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-61,NDC,outpatient,180,ML,12.46,8.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-04,NDC,outpatient,5,ML,14,9.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-82,NDC,outpatient,10,ML,19.54,13.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIFAMPIN 10 MG/ML ORAL SUSPENSION,RX-400484,CDM,S5000,HCPCS,259,RC,99999-0001-44,NDC,outpatient,120,ML,34,23.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,,,outpatient,12.5,ME,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,99999-0002-12,NDC,outpatient,12.5,ME,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,SH040-0403-01,NDC,outpatient,12.5,ME,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFAZOLIN EYE DROPS 50 MG/ML 20 ML BOTTLE,RX-400598,CDM,S5000,HCPCS,259,RC,SH408-0378-01,NDC,outpatient,20,ML,18.41,12.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,SH040-0620-01,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,,,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISONIAZID 100 MG ORAL TABS,RX-4026,CDM,S5000,HCPCS,259,RC,00555-0066-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-73,NDC,outpatient,20,ML,18.34,12.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-25,NDC,outpatient,4,ML,8,5.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-16,NDC,outpatient,20,ML,18.34,12.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-01,NDC,outpatient,4,ML,8,5.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,00548-9502-00,NDC,outpatient,5,ML,246.51,172.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-05,NDC,outpatient,5,ML,1453.64,1017.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-07,NDC,outpatient,5,ML,1453.64,1017.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,59762-0118-03,NDC,outpatient,1,UN,22.5,15.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,69918-0560-30,NDC,outpatient,1,UN,7.56,5.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SOLIFENACIN SUCCINATE 5 MG ORAL TABS,RX-40392,CDM,S5000,HCPCS,259,RC,51248-0150-01,NDC,outpatient,1,UN,52.84,36.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,74312-0035-95,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,00743-1203-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-11,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ISOSORBIDE DINITRATE 20 MG ORAL TABS,RX-4065,CDM,S5000,HCPCS,259,RC,00904-6620-61,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-20,NDC,outpatient,250,ML,30.14,21.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-10,NDC,outpatient,500,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROMORPHONE 100 MG/100 ML INFUSION,RX-4080055,CDM,S5000,HCPCS,250,RC,99999-0000-26,NDC,outpatient,100,ML,168.65,118.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM ADDVANTAGE INFUSION IN NS,RX-4080056,CDM,S5000,HCPCS,250,RC,99999-0000-00,NDC,outpatient,100,ML,54.5,38.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70092-1093-37,NDC,outpatient,250,ML,130.86,91.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0202-40,NDC,outpatient,250,ML,236.1,165.27,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0229-40,NDC,outpatient,250,ML,277.66,194.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,99999-0001-54,NDC,outpatient,250,ML,37.36,26.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,70004-0442-40,NDC,outpatient,250,ML,112.79,78.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,99999-9990-03,NDC,outpatient,250,ML,37.81,26.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE INFUSION 250 MG IN D5W 250 ML PREMIX,RX-4080096,CDM,S5000,HCPCS,250,RC,99999-0001-61,NDC,outpatient,250,ML,35.02,24.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-01,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-00,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-25,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-22,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,00065-0426-36,NDC,outpatient,15,ML,27.17,19.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,57896-0181-05,NDC,outpatient,15,ML,5.55,3.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAFCILLIN SODIUM 1 G IJ WRAPPER,RX-4080106,CDM,S5000,HCPCS,250,RC,63323-0327-10,NDC,outpatient,1,UN,15.49,10.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,44567-0222-10,NDC,outpatient,1,UN,90.46,63.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,63323-0328-20,NDC,outpatient,1,UN,24.64,17.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,55150-0123-15,NDC,outpatient,1,UN,30.45,21.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70092-1650-05,NDC,outpatient,250,ML,102.2,71.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70004-0781-40,NDC,outpatient,250,ML,123.78,86.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,71266-5020-02,NDC,outpatient,250,ML,112.97,79.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,42852-0838-25,NDC,outpatient,250,ML,158.85,111.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70004-0812-40,NDC,outpatient,250,ML,93.12,65.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70092-9170-05,NDC,outpatient,250,ML,146.26,102.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,70004-0811-40,NDC,outpatient,250,ML,109.23,76.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,71506-0010-58,NDC,outpatient,250,ML,88.76,62.132,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN DEXTROSE 1250 MG/250 ML IV SOLN,RX-4080122,CDM,S5000,HCPCS,250,RC,99999-0000-46,NDC,outpatient,275,ML,64.38,45.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN HCL IN DEXTROSE 1500 MG/250 ML IV SOLN,RX-4080123,CDM,S5000,HCPCS,250,RC,99999-0000-47,NDC,outpatient,280,ML,80.8,56.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARDIOPLEGIA SOLN HIGH POTASSIUM 4:1 INDUCTION,RX-4080154,CDM,S5000,HCPCS,250,RC,72196-0101-01,NDC,outpatient,500,ML,673.36,471.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARDIOPLEGIA SOLN LOW POTASSION 4:1 REPERFUSATE,RX-4080155,CDM,S5000,HCPCS,250,RC,71285-0007-01,NDC,outpatient,238.75,ML,1537.64,1076.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARDIOPLEGIA SOLN LOW POTASSIUM 4:1 MAINTENANCE,RX-4080156,CDM,S5000,HCPCS,250,RC,72196-0104-01,NDC,outpatient,1000,ML,1042.09,729.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CONCENTRATED DILAUDID 1 MG/ML PCA,RX-4080157,CDM,S5000,HCPCS,250,RC,70004-0303-62,NDC,outpatient,50,ML,212.25,148.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILAUDID 0.2 MG/ML PCA (HYDROMORPHONE),RX-4080159,CDM,S5000,HCPCS,250,RC,70004-0300-62,NDC,outpatient,50,ML,69.63,48.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRISMASATE K 0/CA 3.5 CRRT SOLUTION,RX-4080163,CDM,S5000,HCPCS,250,RC,00000-1053-53,NDC,outpatient,5000,ML,188.44,131.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-1202-75,NDC,outpatient,100,ML,258.44,180.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70004-0231-64,NDC,outpatient,100,ML,109.23,76.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-9202-75,NDC,outpatient,100,ML,251.94,176.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,99999-0001-52,NDC,outpatient,100,ML,30.84,21.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 5 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080169,CDM,S5000,HCPCS,250,RC,99999-0001-55,NDC,outpatient,100,ML,34.55,24.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080170,CDM,S5000,HCPCS,250,RC,99999-0000-03,NDC,outpatient,100,ML,67.18,47.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-22,NDC,outpatient,2,ML,6.33,4.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-12,NDC,outpatient,2,ML,6.33,4.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-21,NDC,outpatient,1,ML,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-01,NDC,outpatient,1,ML,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,70004-0756-12,NDC,outpatient,10,ML,39.83,27.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,99999-0001-50,NDC,outpatient,10,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-01,NDC,outpatient,10,ML,22.61,15.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-01,NDC,outpatient,5,ML,14.35,10.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-10,NDC,outpatient,5,ML,14.35,10.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-10,NDC,outpatient,10,ML,22.61,15.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE-LIDOCAINE 0.3%-1.5% OINT,RX-408020,CDM,S5000,HCPCS,259,RC,00000-0000-03,NDC,outpatient,30,GR,333.75,233.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-05,NDC,outpatient,5,ML,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-15,NDC,outpatient,5,ML,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,71399-2829-01,NDC,outpatient,28,GR,14.21,9.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,00536-1211-95,NDC,outpatient,28,GR,13.84,9.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COCOA BUTTER STICK,RX-4080278,CDM,S5000,HCPCS,259,RC,07570-7011-00,NDC,outpatient,30,ML,4.41,3.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAPSAICIN 0.025 % EX CREAM WRAPPER,RX-4080289,CDM,S5000,HCPCS,259,RC,00536-2525-25,NDC,outpatient,60,GR,10.95,7.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-04,NDC,outpatient,5,GR,24.68,17.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-31,NDC,outpatient,30,GR,87.18,61.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,00168-0357-55,NDC,outpatient,5,GR,29.95,20.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,99999-0000-54,NDC,outpatient,20,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,SH408-0358-01,NDC,outpatient,20,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MULTIVITAMIN CHILDRENS ORAL CHEW WRAPPER,RX-4080360,CDM,S5000,HCPCS,259,RC,80681-0049-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMPHOTERICIN B EYE DROPS 0.2 MG/ML 10 ML BOTTLE,RX-4080376,CDM,S5000,HCPCS,259,RC,SH408-0376-01,NDC,outpatient,10,ML,61.86,43.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 1 MG/ML ORAL SUSPENSION 81 ML FOR ASA DESENSITIZATION,RX-4080380,CDM,S5000,HCPCS,259,RC,SH408-0380-01,NDC,outpatient,81,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFTAZIDIME EYE DROPS 22.5 MG/ML SYRINGE,RX-4080386,CDM,S5000,HCPCS,259,RC,99999-0000-32,NDC,outpatient,1,ML,37.46,26.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN MOUTH WASH 3 MG/ML,RX-4080388,CDM,S5000,HCPCS,259,RC,99999-0000-33,NDC,outpatient,250,ML,10.02,7.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,99999-0003-19,NDC,outpatient,3,ML,14.57,10.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,69623-0801-14,NDC,outpatient,3,ML,35.6,24.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,70092-1135-44,NDC,outpatient,3,ML,49.22,34.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,88888-0926-28,NDC,outpatient,3,ML,22.25,15.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAG SULFATE-GLYCERIN-WATER ENEMA 180 ML,RX-4080412,CDM,S5000,HCPCS,259,RC,00000-0000-02,NDC,outpatient,180,ML,28.04,19.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE ORAL SUSPENSION 1 MG/ML,RX-4080416,CDM,S5000,HCPCS,259,RC,99999-0003-46,NDC,outpatient,12.5,ML,1.93,1.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-08,NDC,outpatient,237,ML,159.26,111.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-20,NDC,outpatient,20,ML,98.71,69.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-36,NDC,outpatient,5,ML,2.94,2.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,69238-2122-20,NDC,outpatient,20,ML,14.96,10.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0885-16,NDC,outpatient,480,ML,1149.17,804.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-37,NDC,outpatient,240,ML,1184.42,829.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-20,NDC,outpatient,20,ML,13.44,9.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,42799-0815-01,NDC,outpatient,237,ML,151.87,106.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-35,NDC,outpatient,20,ML,13.44,9.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,SH408-0423-01,NDC,outpatient,1,ML,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,99999-0001-12,NDC,outpatient,1,ML,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 1 MEQ/ML 1 ML ORAL SYRINGE,RX-4080424,CDM,S5000,HCPCS,259,RC,99999-0001-25,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE-MINERAL OIL-GLYCERIN ENEMA,RX-4080430,CDM,S5000,HCPCS,259,RC,SH408-0430-01,NDC,outpatient,135,ML,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,99999-0001-26,NDC,outpatient,1.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,,,outpatient,1.5,ML,1.92,1.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SPIRONOLACTONE 6 MG/3 ML ORAL SYRINGE,RX-4080435,CDM,S5000,HCPCS,259,RC,99999-0000-28,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFAZOLIN IVPB 2 G IN 100 ML NS PREMIX,RX-4080437,CDM,S5000,HCPCS,250,RC,99999-0000-45,NDC,outpatient,100,ML,47.78,33.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0450-01,NDC,outpatient,0.1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0449-01,NDC,outpatient,2,ML,22.21,15.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN EYE SOLUTION 25 MG/ML,RX-4080451,CDM,S5000,HCPCS,259,RC,SH408-0451-01,NDC,outpatient,20,ML,54.07,37.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VANCOMYCIN EYE SOLUTION 50 MG/ML ,RX-4080452,CDM,S5000,HCPCS,259,RC,SH408-0452-01,NDC,outpatient,20,ML,54.07,37.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,76282-0327-01,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,51672-4027-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,99999-0002-46,NDC,outpatient,0.5,ME,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,51672-4029-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,99999-0002-47,NDC,outpatient,1.25,ME,4.53,3.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0315-25,NDC,outpatient,250,ML,118.35,82.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0533-25,NDC,outpatient,250,ML,140.6,98.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0785-40,NDC,outpatient,250,ML,301.03,210.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-01,NDC,outpatient,250,ML,261.87,183.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0775-40,NDC,outpatient,250,ML,320.83,224.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1468-05,NDC,outpatient,250,ML,192.22,134.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1652-05,NDC,outpatient,250,ML,216.97,151.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-03,NDC,outpatient,250,ML,261.87,183.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,48433-0108-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,00904-7191-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70004-0750-09,NDC,outpatient,5,ML,78.06,54.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,69374-0932-03,NDC,outpatient,3,ML,45.62,31.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-30,NDC,outpatient,3,ML,51.74,36.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-13,NDC,outpatient,3,ML,51.74,36.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70092-1084-44,NDC,outpatient,5,ML,61.01,42.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,20555-0019-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,00574-0508-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,00065-0518-01,NDC,outpatient,3.5,GR,29.43,20.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,10119-0022-39,NDC,outpatient,3.5,GR,30.17,21.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 1 % FOR PLEURODESIS,RX-4080551,CDM,S5000,HCPCS,250,RC,99999-0003-43,NDC,outpatient,50,ML,13.37,9.359,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-09,NDC,outpatient,5,ML,93.68,65.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-29,NDC,outpatient,5,ML,93.68,65.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-01,NDC,outpatient,15,ML,59.41,41.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-11,NDC,outpatient,15,ML,59.41,41.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,00799-0001-04,NDC,outpatient,113,GR,20.12,14.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,10135-0701-04,NDC,outpatient,113,GR,13.58,9.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM 100 MG ADDVANTAGE INFUSION IN D5W 100 ML,RX-4080558,CDM,S5000,HCPCS,250,RC,99999-0000-01,NDC,outpatient,100,ML,48.09,33.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HIV POST EXPOSURE KIT,RX-4080559,CDM,S5000,HCPCS,259,RC,SH408-0559-01,NDC,outpatient,1,UN,1178.97,825.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE 0.125 % IN 100 ML NS NERVE BLOCK CASSETTE,RX-4080570,CDM,S5000,HCPCS,250,RC,61553-0829-48,NDC,outpatient,100,ML,76.93,53.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080589,CDM,S5000,HCPCS,250,RC,99999-0000-04,NDC,outpatient,100,ML,79.95,55.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VEIN GRAFT SOLUTION,RX-4080591,CDM,S5000,HCPCS,250,RC,99999-0000-07,NDC,outpatient,505.67,ML,73.5,51.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLECAINIDE ACETATE 20 MG/ML ORAL SUSP,RX-4080607,CDM,S5000,HCPCS,259,RC,99999-0003-52,NDC,outpatient,2.5,ML,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYOSCYAMINE SULFATE 0.125 MG SL SUBL WRAPPER,RX-4080632,CDM,S5000,HCPCS,259,RC,42192-0338-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-46,NDC,outpatient,60,ML,33.11,23.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-51,NDC,outpatient,60,ML,33.11,23.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0923-41,NDC,outpatient,60,ML,80.91,56.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,10006-0700-28,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM GLUCONATE 500 MG ORAL TABS WRAPPER,RX-4080642,CDM,S5000,HCPCS,259,RC,60258-0172-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GI COCKTAIL SUSPENSION,RX-4080647,CDM,S5000,HCPCS,259,RC,99999-0000-39,NDC,outpatient,55,ML,82.33,57.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARDIOPLEGIA SOLN DEL NIDO,RX-4080676,CDM,S5000,HCPCS,250,RC,99999-0004-39,NDC,outpatient,1052.8,ML,113.01,79.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1617-46,NDC,outpatient,10,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1512-46,NDC,outpatient,10,ML,20.96,14.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IV SOLN MINI-BAG 100 ML,RX-4080711,CDM,S5000,HCPCS,250,RC,00338-0553-18,NDC,outpatient,100,ML,29.37,20.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HYDROCORTISONE ORAL SUSPENSION 2.5 MG/ML COMPOUNDED PRODUCT,RX-4080716,CDM,S5000,HCPCS,259,RC,99999-0000-80,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUDROCORTISONE ACETATE SUSP 0.2 MG/ML,RX-4080718,CDM,S5000,HCPCS,259,RC,99999-0000-81,NDC,outpatient,1,ML,4.96,3.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,74300-0000-71,NDC,outpatient,113,GR,26.15,18.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,62103-0323-02,NDC,outpatient,57,GR,14.72,10.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALOXONE INHALATION KIT - HOSPITAL USE ONLY,RX-4080774,CDM,S5000,HCPCS,259,RC,99999-0000-90,NDC,outpatient,1,UN,110.81,77.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-11,NDC,outpatient,20,ML,230.78,161.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-01,NDC,outpatient,20,ML,230.78,161.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFAZOLIN IVPB 3 G IN 100 ML NS PREMIX,RX-4080801,CDM,S5000,HCPCS,250,RC,99999-0001-10,NDC,outpatient,130,ML,33.43,23.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,99999-0000-98,NDC,outpatient,50,ML,59.06,41.342,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,70092-1433-50,NDC,outpatient,50,ML,216.36,151.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 5 % MOUTHWASH ORAL SUSPENSION,RX-4080811,CDM,S5000,HCPCS,259,RC,99999-0001-06,NDC,outpatient,169,ML,77.47,54.229,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,50580-0170-05,NDC,outpatient,5,ML,1.37,0.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,99999-0001-17,NDC,outpatient,5,ML,1.37,0.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,00045-0166-04,NDC,outpatient,120,ML,28.31,19.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BABY BUTT BALM,RX-4080852,CDM,S5000,HCPCS,259,RC,99999-0001-13,NDC,outpatient,118.7,GR,70.96,49.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAZOLAMIDE 25 MG/ML SUSPENSION,RX-4080874,CDM,S5000,HCPCS,259,RC,99999-0001-21,NDC,outpatient,5,ML,10.93,7.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-15,NDC,outpatient,15,ML,2.32,1.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-59,NDC,outpatient,15,ML,7.68,5.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-30,NDC,outpatient,15,ML,2.32,1.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-61,NDC,outpatient,15,ML,7.68,5.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,69618-0008-58,NDC,outpatient,15,ML,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,99999-0002-20,NDC,outpatient,15,ML,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00005-4344-62,NDC,outpatient,15,ML,2.09,1.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-02,NDC,outpatient,8,ML,9.33,6.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-08,NDC,outpatient,8,ML,47.67,33.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,38779-1284-08,NDC,outpatient,8,ML,2.35,1.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,49452-3081-02,NDC,outpatient,8,ML,2.35,1.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-01,NDC,outpatient,15,ML,169.35,118.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0170-05,NDC,outpatient,5,ML,35.56,24.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-16,NDC,outpatient,15,ML,169.35,118.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-01,NDC,outpatient,5,ML,79.73,55.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-06,NDC,outpatient,5,ML,79.73,55.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,66794-0228-41,NDC,outpatient,5,ML,6.84,4.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0225-05,NDC,outpatient,5,ML,9.23,6.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0226-10,NDC,outpatient,10,ML,18.46,12.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-10,NDC,outpatient,5,ML,24.17,16.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-10,NDC,outpatient,5,ML,10.46,7.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-05,NDC,outpatient,10,ML,22.61,15.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-06,NDC,outpatient,10,ML,22.61,15.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,43066-0007-10,NDC,outpatient,5,ML,8.46,5.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-05,NDC,outpatient,5,ML,7.05,4.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,67457-0228-02,NDC,outpatient,5,ML,6.84,4.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-01,NDC,outpatient,5,ML,10.46,7.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,25021-0662-05,NDC,outpatient,5,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-02,NDC,outpatient,5,ML,7.05,4.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-01,NDC,outpatient,5,ML,24.17,16.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMIODARONE ORAL SUSPENSION 40 MG/ML,RX-4080970,CDM,S5000,HCPCS,259,RC,99999-0001-63,NDC,outpatient,10,ML,2.04,1.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 100 MG/100 ML IN D5W PF PREMIX,RX-4081012,CDM,S5000,HCPCS,250,RC,99999-0000-99,NDC,outpatient,100,ML,312.37,218.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-07,NDC,outpatient,10,ML,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-10,NDC,outpatient,10,ML,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,42023-0243-01,NDC,outpatient,10,ML,42.55,29.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,99999-0000-87,NDC,outpatient,100,ML,34.01,23.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DILTIAZEM 100 MG IN 100 ML NS BATCHED INFUSION,RX-4081050,CDM,S5000,HCPCS,250,RC,99999-0002-64,NDC,outpatient,100,ML,56.68,39.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
URSODIOL 50 MG/ML ORAL SUSPENSION,RX-4081064,CDM,S5000,HCPCS,259,RC,99999-0002-69,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPRENORPHINE-NALOXONE (SUBOXONE) SL FILM 8 MG-2 MG KIT,RX-4081171,CDM,S5000,HCPCS,259,RC,99999-0003-16,NDC,outpatient,1,UN,142.33,99.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-05,NDC,outpatient,5,ML,19.63,13.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-15,NDC,outpatient,5,ML,19.63,13.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-11,NDC,outpatient,5,ML,17.92,12.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,63323-0208-05,NDC,outpatient,5,ML,7.41,5.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,76329-3390-01,NDC,outpatient,5,ML,27.15,19.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-34,NDC,outpatient,5,ML,17.92,12.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,12.64,8.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,12.64,8.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 100 MG/100 ML IN NS PF PREMIX,RX-4081195,CDM,S5000,HCPCS,250,RC,99999-0003-26,NDC,outpatient,100,ML,312.37,218.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANTOPRAZOLE 80 MG/100 ML INFUSION PREMIX,RX-4081208,CDM,S5000,HCPCS,250,RC,99999-0000-77,NDC,outpatient,100,ML,36.56,25.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-10,NDC,outpatient,200,ML,242.06,169.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-01,NDC,outpatient,200,ML,242.06,169.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 3 % IV ONCE,RX-4081432,CDM,S5000,HCPCS,250,RC,99999-0003-86,NDC,outpatient,100,ML,18.06,12.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FAMOTIDINE IN NACL 20-0.9 MG/10 ML-% IV SOSY,RX-4081444,CDM,S5000,HCPCS,250,RC,99999-0003-96,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM HYALURONATE 10 MG/ML IO SOLN WRAPPER,RX-4081458,CDM,S5000,HCPCS,250,RC,05047-4508-38,NDC,outpatient,0.4,ML,397.92,278.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV *BATCHED*,RX-4081542,CDM,S5000,HCPCS,250,RC,99999-0004-35,NDC,outpatient,50,ML,157.29,110.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,99999-0004-53,NDC,outpatient,100,ML,48.85,34.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,70092-1518-75,NDC,outpatient,100,ML,209.09,146.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,0.5,UN,4.12,2.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,0.5,UN,2.9,2.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,0.5,UN,1,0.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHADONE 10 MG TABLET DISCHARGE KIT,RX-4081610,CDM,S5000,HCPCS,259,RC,99999-0004-50,NDC,outpatient,1,UN,6.15,4.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRISMASATE K 4/CA 2.5 CRRT SOLUTION,RX-40840045,CDM,S5000,HCPCS,250,RC,SH408-4045-01,NDC,outpatient,5000,ML,188.44,131.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRISMASATE K 2/CA 0 CRRT SOLUTION,RX-40840046,CDM,S5000,HCPCS,250,RC,SH408-4046-01,NDC,outpatient,5000,ML,188.44,131.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0011-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0012-66,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,47335-0835-83,NDC,outpatient,1,UN,5.27,3.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,63629-2364-01,NDC,outpatient,1,UN,6.03,4.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,S5000,HCPCS,259,RC,00597-0087-17,NDC,outpatient,12.9,GR,1940.98,1358.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENTECAVIR 0.5 MG ORAL TABS,RX-41147,CDM,S5000,HCPCS,259,RC,00003-1611-12,NDC,outpatient,1,UN,197.48,138.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENTECAVIR 1 MG ORAL TABS,RX-41148,CDM,S5000,HCPCS,259,RC,65862-0842-30,NDC,outpatient,1,UN,8.95,6.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-98,NDC,outpatient,1,UN,50.62,35.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-16,NDC,outpatient,1,UN,50.62,35.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-11,NDC,outpatient,1,UN,21.37,14.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-47,NDC,outpatient,1,UN,21.37,14.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,49483-0687-03,NDC,outpatient,1,UN,4.45,3.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,65862-0936-30,NDC,outpatient,1,UN,5.24,3.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,99999-0002-52,NDC,outpatient,10,ML,6.37,4.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,52817-0830-04,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-05,NDC,outpatient,0.5,ML,58.03,40.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-00,NDC,outpatient,0.5,ML,58.19,40.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-02,NDC,outpatient,0.5,ML,64.31,45.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-01,NDC,outpatient,0.5,ML,58.03,40.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OMEGA-3-ACID ETHYL ESTERS 1 G ORAL CAPS,RX-41822,CDM,S5000,HCPCS,259,RC,64380-0761-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,65162-0918-38,NDC,outpatient,35.44,GR,50,35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,64380-0789-32,NDC,outpatient,35.44,GR,61.67,43.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,63739-0072-33,NDC,outpatient,1,UN,2.21,1.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,00904-6671-04,NDC,outpatient,1,UN,2.21,1.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METRONIDAZOLE 1 % EX GEL,RX-41899,CDM,S5000,HCPCS,259,RC,51672-4215-03,NDC,outpatient,60,GR,258.99,181.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AVEENO SOOTHING BATH TREATMENT EX PACK,RX-41904,CDM,S5000,HCPCS,259,RC,08137-0036-40,NDC,outpatient,1,UN,2.74,1.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-11,NDC,outpatient,1,UN,11.47,8.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,70010-0028-03,NDC,outpatient,1,UN,6.31,4.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-15,NDC,outpatient,1,UN,11.47,8.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,00054-0622-63,NDC,outpatient,5,ML,3.5,2.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,99999-0003-12,NDC,outpatient,5,ML,5.06,3.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-11,NDC,outpatient,1,UN,1.96,1.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,50228-0350-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-01,NDC,outpatient,1,UN,1.96,1.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00071-1013-41,NDC,outpatient,1,UN,45.77,32.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,72205-0012-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00904-6992-61,NDC,outpatient,1,UN,2.3,1.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00071-1014-41,NDC,outpatient,1,UN,45.77,32.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-01,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-11,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,62332-0121-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00904-7000-61,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,62332-0122-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,00904-7001-61,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,69238-1313-09,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00071-1016-41,NDC,outpatient,1,UN,45.77,32.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00904-7002-61,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,S5000,HCPCS,250,RC,42023-0113-10,NDC,outpatient,20,ML,41.57,29.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,S5000,HCPCS,250,RC,42023-0115-10,NDC,outpatient,5,ML,53.45,37.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-10,NDC,outpatient,10,ML,23.23,16.261,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-01,NDC,outpatient,10,ML,23.23,16.261,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-15,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-11,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,70756-0201-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,00781-1487-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-01,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-11,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,99999-0004-03,NDC,outpatient,2.5,ML,25.53,17.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,00054-0057-46,NDC,outpatient,60,ML,612.5,428.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-01,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-11,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,S5000,HCPCS,259,RC,76329-6300-05,NDC,outpatient,4,ML,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMMONIA AROMATIC IN INHA,RX-439,CDM,S5000,HCPCS,259,RC,67777-0251-01,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00555-0484-02,NDC,outpatient,1,UN,5.35,3.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00054-8496-19,NDC,outpatient,1,UN,7.46,5.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-01,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-20,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-01,NDC,outpatient,1,UN,1.54,1.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-11,NDC,outpatient,1,UN,1.54,1.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-20,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,00074-4552-11,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-01,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-11,NDC,outpatient,1,UN,1.67,1.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-01,NDC,outpatient,1,UN,1.67,1.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-11,NDC,outpatient,1,UN,2.04,1.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-20,NDC,outpatient,1,UN,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-01,NDC,outpatient,1,UN,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-01,NDC,outpatient,1,UN,2.04,1.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-20,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,00074-6624-11,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-20,NDC,outpatient,1,UN,3.14,2.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-01,NDC,outpatient,1,UN,3.14,2.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,00074-7069-11,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,60687-0530-01,NDC,outpatient,1,UN,2.51,1.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00054-3505-47,NDC,outpatient,50,ML,107.03,74.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00527-6004-80,NDC,outpatient,50,ML,75.88,53.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,60432-0465-51,NDC,outpatient,50,ML,131.72,92.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 0.5 % IJ SOLN,RX-4451,CDM,S5000,HCPCS,250,RC,63323-0484-57,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-02,NDC,outpatient,50,ML,8.23,5.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-16,NDC,outpatient,20,ML,4.63,3.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-01,NDC,outpatient,20,ML,4.63,3.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-17,NDC,outpatient,50,ML,8.23,5.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-16,NDC,outpatient,20,ML,5.14,3.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0255-20,NDC,outpatient,20,ML,4.22,2.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-17,NDC,outpatient,10,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-02,NDC,outpatient,2,ML,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-01,NDC,outpatient,10,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-26,NDC,outpatient,20,ML,8.02,5.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-27,NDC,outpatient,20,ML,18.2,12.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-01,NDC,outpatient,20,ML,5.14,3.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0254-10,NDC,outpatient,10,ML,3.76,2.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-01,NDC,outpatient,2,ML,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-02,NDC,outpatient,20,ML,18.2,12.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,16714-0298-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,65862-0016-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,00093-2178-01,NDC,outpatient,1,UN,3.21,2.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,51862-0321-01,NDC,outpatient,1,UN,3.45,2.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,59762-1207-01,NDC,outpatient,1,UN,3.28,2.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN 500 MG ORAL CAPS,RX-451,CDM,S5000,HCPCS,259,RC,16714-0299-03,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LITHIUM CARBONATE 150 MG ORAL CAPS,RX-4528,CDM,S5000,HCPCS,259,RC,00054-8526-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,31722-0545-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,00054-8527-25,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00143-9889-15,NDC,outpatient,150,ML,20.7,14.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00093-4155-79,NDC,outpatient,80,ML,14.6,10.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,99999-0002-83,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-01,NDC,outpatient,1,UN,3,2.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-20,NDC,outpatient,1,UN,3,2.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-01,NDC,outpatient,1,UN,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-11,NDC,outpatient,1,UN,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00054-3532-44,NDC,outpatient,30,ML,100.26,70.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,99999-0001-38,NDC,outpatient,1,ML,3.55,2.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00121-0770-01,NDC,outpatient,30,ML,33.11,23.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,13107-0083-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,69315-0904-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00093-3425-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00904-6008-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00093-3426-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOXAPINE SUCCINATE 25 MG ORAL CAPS,RX-4600,CDM,S5000,HCPCS,259,RC,00591-0371-01,NDC,outpatient,1,UN,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LOXAPINE SUCCINATE 5 MG ORAL CAPS,RX-4601,CDM,S5000,HCPCS,259,RC,00591-0369-01,NDC,outpatient,1,UN,1.31,0.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MAGNESIUM CITRATE 1.745 GM/30ML ORAL SOLN,RX-4711,CDM,S5000,HCPCS,259,RC,70677-1111-01,NDC,outpatient,296,ML,7.91,5.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-02,NDC,outpatient,250,ML,79.42,55.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-03,NDC,outpatient,500,ML,93.88,65.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-03,NDC,outpatient,500,ML,80.53,56.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-13,NDC,outpatient,500,ML,93.88,65.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEDROXYPROGESTERONE ACETATE 10 MG ORAL TABS,RX-4854,CDM,S5000,HCPCS,259,RC,00555-0779-02,NDC,outpatient,1,UN,1.07,0.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MEDROXYPROGESTERONE ACETATE 2.5 MG ORAL TABS,RX-4855,CDM,S5000,HCPCS,259,RC,00555-0872-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00054-0710-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-23,NDC,outpatient,1,UN,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-62,NDC,outpatient,1,UN,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-23,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-62,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHAZOLAMIDE 50 MG ORAL TABS,RX-4962,CDM,S5000,HCPCS,259,RC,00574-0791-01,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,00904-7057-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,31722-0533-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,76385-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-21,NDC,outpatient,1,UN,5.13,3.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-11,NDC,outpatient,1,UN,5.13,3.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,00406-1144-01,NDC,outpatient,1,UN,1.43,1.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPREDNISOLONE 16 MG ORAL TABS,RX-4992,CDM,S5000,HCPCS,259,RC,59762-0050-01,NDC,outpatient,1,UN,8.54,5.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,00904-6914-61,NDC,outpatient,1,UN,4.37,3.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-11,NDC,outpatient,1,UN,4.95,3.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-01,NDC,outpatient,1,UN,4.95,3.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-01,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-11,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METRONIDAZOLE 250 MG ORAL TABS,RX-5015,CDM,S5000,HCPCS,259,RC,00904-7156-61,NDC,outpatient,1,UN,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-01,NDC,outpatient,1,UN,2.17,1.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-11,NDC,outpatient,1,UN,2.17,1.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,29300-0227-01,NDC,outpatient,1,UN,1.76,1.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,S5000,HCPCS,259,RC,61269-0735-14,NDC,outpatient,14,GR,7.54,5.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,99999-0002-15,NDC,outpatient,30,ML,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,48433-0202-30,NDC,outpatient,30,ML,5.08,3.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINOCYCLINE HCL 50 MG ORAL CAPS,RX-5111,CDM,S5000,HCPCS,259,RC,00591-5694-60,NDC,outpatient,1,UN,1.26,0.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-01,NDC,outpatient,1,UN,2.48,1.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-11,NDC,outpatient,1,UN,2.48,1.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,00591-5642-01,NDC,outpatient,1,UN,1.01,0.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-11,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-01,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00054-0237-49,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-59,NDC,outpatient,5,ML,4.7,3.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-62,NDC,outpatient,5,ML,4.7,3.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-05,NDC,outpatient,5,ML,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-94,NDC,outpatient,5,ML,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,99999-0002-19,NDC,outpatient,5,ML,2.14,1.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-24,NDC,outpatient,1,UN,3.2,2.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-25,NDC,outpatient,1,UN,2.1,1.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MORPHINE SULFATE 10 MG RE SUPP,RX-5180,CDM,S5000,HCPCS,259,RC,00574-7112-12,NDC,outpatient,1,UN,19.66,13.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-25,NDC,outpatient,1,UN,11.38,7.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-95,NDC,outpatient,1,UN,11.38,7.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,00904-7071-07,NDC,outpatient,1,UN,9.11,6.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,69097-0868-07,NDC,outpatient,1,UN,1.13,0.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,65162-0188-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,65162-0189-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65162-0190-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,63739-0403-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65862-0522-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-05,NDC,outpatient,1,UN,3.09,2.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-07,NDC,outpatient,1,UN,3.09,2.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,S5000,HCPCS,259,RC,24208-0790-62,NDC,outpatient,10,ML,150.86,105.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIACIN 100 MG ORAL TABS,RX-5539,CDM,S5000,HCPCS,259,RC,80681-0057-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NIFEDIPINE 10 MG ORAL CAPS,RX-5558,CDM,S5000,HCPCS,259,RC,23155-0194-01,NDC,outpatient,1,UN,1.98,1.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAPS,RX-5595,CDM,S5000,HCPCS,259,RC,57664-0232-88,NDC,outpatient,1,UN,3.41,2.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,68462-0638-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,72888-0138-01,NDC,outpatient,1,UN,1.43,1.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,00071-0417-24,NDC,outpatient,1,UN,3.05,2.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-11,NDC,outpatient,0.75,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-35,NDC,outpatient,0.75,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-45,NDC,outpatient,0.75,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-25,NDC,outpatient,0.75,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,S5000,HCPCS,259,RC,00281-0326-08,NDC,outpatient,1,GR,9.96,6.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-11,NDC,outpatient,1,UN,1.89,1.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-01,NDC,outpatient,1,UN,1.89,1.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,00713-0678-15,NDC,outpatient,15,GR,53.4,37.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,45802-0059-35,NDC,outpatient,15,GR,17.03,11.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,51672-1289-01,NDC,outpatient,15,GR,18.83,13.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,45802-0048-35,NDC,outpatient,15,GR,13.29,9.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,00472-0166-15,NDC,outpatient,15,GR,61.35,42.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-00,NDC,outpatient,5,ML,4.74,3.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-1045-16,NDC,outpatient,5,ML,4.21,2.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-10,NDC,outpatient,5,ML,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,99999-0003-91,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-05,NDC,outpatient,5,ML,4.74,3.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-70,NDC,outpatient,5,ML,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,S5000,HCPCS,259,RC,51672-1263-01,NDC,outpatient,15,GR,15.02,10.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,S5000,HCPCS,259,RC,51672-1272-01,NDC,outpatient,15,GR,22.37,15.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ORA-PLUS ORAL LIQD,RX-5851,CDM,S5000,HCPCS,259,RC,00574-0303-16,NDC,outpatient,473,ML,130.96,91.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ORA-SWEET SF ORAL SYRP,RX-5853,CDM,S5000,HCPCS,259,RC,00574-0302-16,NDC,outpatient,473,ML,130.96,91.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,00228-2067-10,NDC,outpatient,1,UN,3.24,2.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-11,NDC,outpatient,1,UN,8.63,6.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-01,NDC,outpatient,1,UN,8.63,6.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-01,NDC,outpatient,1,UN,9.09,6.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-11,NDC,outpatient,1,UN,9.09,6.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,00904-7027-61,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-11,NDC,outpatient,1,UN,1.85,1.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-01,NDC,outpatient,1,UN,1.85,1.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-23,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-62,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-01,NDC,outpatient,2,ML,69.91,48.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-10,NDC,outpatient,2,ML,69.91,48.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,00517-4002-25,NDC,outpatient,2,ML,103.84,72.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-07,NDC,outpatient,2,ML,78.96,55.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-05,NDC,outpatient,2,ML,78.96,55.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-95,NDC,outpatient,1,UN,142.02,99.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-94,NDC,outpatient,1,UN,142.02,99.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,99999-0002-88,NDC,outpatient,10,ML,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,00093-4127-73,NDC,outpatient,100,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENICILLIN V POTASSIUM 250 MG ORAL TABS,RX-6092,CDM,S5000,HCPCS,259,RC,57237-0040-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00093-1174-01,NDC,outpatient,1,UN,1.67,1.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00143-9836-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PERPHENAZINE 2 MG ORAL TABS,RX-6157,CDM,S5000,HCPCS,259,RC,00904-6599-61,NDC,outpatient,1,UN,2.75,1.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PERPHENAZINE 8 MG ORAL TABS,RX-6159,CDM,S5000,HCPCS,259,RC,00904-6601-61,NDC,outpatient,1,UN,5.02,3.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENAZOPYRIDINE HCL 100 MG ORAL TABS,RX-6193,CDM,S5000,HCPCS,259,RC,65162-0681-10,NDC,outpatient,1,UN,1.61,1.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-05,NDC,outpatient,5,ML,7.01,4.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-50,NDC,outpatient,5,ML,7.01,4.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,13517-0107-16,NDC,outpatient,473,ML,307.31,215.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,16571-0675-16,NDC,outpatient,473,ML,82.09,57.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,99999-0002-30,NDC,outpatient,5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,54932-0501-81,NDC,outpatient,473,ML,75.78,53.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,00904-6575-61,NDC,outpatient,1,UN,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,16571-0673-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,S5000,HCPCS,259,RC,00225-0800-47,NDC,outpatient,15,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,S5000,HCPCS,259,RC,00225-0805-47,NDC,outpatient,15,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,S5000,HCPCS,259,RC,00225-0810-47,NDC,outpatient,15,ML,15.09,10.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYLEPHRINE HCL 2.5 % OP SOLN,RX-6246,CDM,S5000,HCPCS,259,RC,70756-0629-25,NDC,outpatient,2,ML,146.94,102.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-62,NDC,outpatient,4,ML,13.48,9.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-66,NDC,outpatient,4,ML,13.48,9.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,57664-0808-88,NDC,outpatient,1,UN,1.19,0.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,65862-0692-01,NDC,outpatient,1,UN,1.74,1.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,S5000,HCPCS,259,RC,61314-0203-15,NDC,outpatient,15,ML,342.03,239.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,70069-0191-01,NDC,outpatient,15,ML,140.98,98.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,61314-0204-15,NDC,outpatient,15,ML,351.44,246.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,S5000,HCPCS,259,RC,61314-0206-15,NDC,outpatient,15,ML,326.81,228.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PIROXICAM 10 MG ORAL CAPS,RX-6310,CDM,S5000,HCPCS,259,RC,42571-0176-01,NDC,outpatient,1,UN,3.12,2.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,00087-0402-03,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,99999-0001-68,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,S5000,HCPCS,250,RC,55150-0234-10,NDC,outpatient,1,UN,16.13,11.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,51754-2001-04,NDC,outpatient,20,ML,18.07,12.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-01,NDC,outpatient,20,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-11,NDC,outpatient,20,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POVIDONE-IODINE 10 % EX SOLN,RX-6458,CDM,S5000,HCPCS,259,RC,52380-1905-00,NDC,outpatient,59,ML,4.73,3.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-01,NDC,outpatient,1,UN,6.21,4.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-11,NDC,outpatient,1,UN,5.34,3.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-20,NDC,outpatient,1,UN,6.21,4.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-01,NDC,outpatient,1,UN,5.34,3.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-20,NDC,outpatient,1,UN,14.76,10.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-01,NDC,outpatient,1,UN,14.76,10.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,60758-0119-05,NDC,outpatient,5,ML,106.58,74.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,61314-0637-05,NDC,outpatient,5,ML,113.48,79.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,11980-0180-05,NDC,outpatient,5,ML,534.23,373.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-8739-25,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,59651-0484-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-4741-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00054-0017-20,NDC,outpatient,1,UN,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00603-5338-21,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00904-6923-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-8740-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-4742-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00904-7127-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00054-0018-20,NDC,outpatient,1,UN,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,59746-0175-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,64380-0785-07,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,00054-8724-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,10135-0779-01,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,59651-0489-01,NDC,outpatient,1,UN,1.61,1.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-20,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-25,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASCORBIC ACID 500 MG/ML IJ SOLN,RX-654,CDM,S5000,HCPCS,250,RC,67157-0101-51,NDC,outpatient,50,ML,1099.15,769.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-11,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-15,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROBENECID 500 MG ORAL TABS,RX-6561,CDM,S5000,HCPCS,259,RC,00591-5347-01,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,99999-0002-39,NDC,outpatient,5,ML,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,27808-0065-02,NDC,outpatient,2.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,24208-0730-06,NDC,outpatient,15,ML,110.61,77.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,61314-0016-01,NDC,outpatient,15,ML,111.21,77.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-05,NDC,outpatient,5,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-40,NDC,outpatient,5,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00054-3727-63,NDC,outpatient,500,ML,209.15,146.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,69238-2077-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,00378-0182-01,NDC,outpatient,1,UN,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-01,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,00603-5484-21,NDC,outpatient,1,UN,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-11,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,67253-0651-10,NDC,outpatient,1,UN,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,00228-2348-10,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-6990-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-5053-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,10135-0735-60,NDC,outpatient,1,UN,15.09,10.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,33342-0447-11,NDC,outpatient,1,UN,19.28,13.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,70954-0484-10,NDC,outpatient,1,UN,17.43,12.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
QUININE SULFATE 324 MG ORAL CAPS,RX-6781,CDM,S5000,HCPCS,259,RC,50742-0238-30,NDC,outpatient,1,UN,2.82,1.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,63739-0434-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-80,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,66553-0002-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,57896-0901-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,66553-0001-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 325 MG ORAL TBEC,RX-685,CDM,S5000,HCPCS,259,RC,57896-0921-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00904-6783-70,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,63739-0212-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00536-1234-41,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ASPIRIN 300 MG RE SUPP,RX-693,CDM,S5000,HCPCS,259,RC,00574-7034-12,NDC,outpatient,1,UN,4.58,3.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN DETEMIR 100 UNIT/ML SC SOLN,RX-70261,CDM,S5000,HCPCS,259,RC,00169-3687-12,NDC,outpatient,10,ML,388.27,271.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-99,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,00904-3865-75,NDC,outpatient,44,ML,3.33,2.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,49348-0356-25,NDC,outpatient,44,ML,5.88,4.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAMADOL HCL ER 200 MG ORAL TB24,RX-70353,CDM,S5000,HCPCS,259,RC,68180-0698-06,NDC,outpatient,1,UN,19.84,13.888,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-11,NDC,outpatient,1,UN,5.07,3.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-21,NDC,outpatient,1,UN,5.08,3.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-15,NDC,outpatient,1,UN,5.07,3.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-11,NDC,outpatient,1,UN,5.08,3.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,68462-0319-60,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LUBIPROSTONE 24 MCG ORAL CAPS,RX-70472,CDM,S5000,HCPCS,259,RC,00254-3029-02,NDC,outpatient,1,UN,4.45,3.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00536-1183-99,NDC,outpatient,9.9,ML,45.6,31.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00054-3270-99,NDC,outpatient,16,GR,32.12,22.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,S5000,HCPCS,259,RC,00002-7511-01,NDC,outpatient,10,ML,211.82,148.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-40,NDC,outpatient,400,GR,153.08,107.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-50,NDC,outpatient,50,GR,55.18,38.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,61570-0131-55,NDC,outpatient,50,GR,30.49,21.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,00904-7206-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,69618-0033-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,49348-0188-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,00536-1303-75,NDC,outpatient,0.3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,49348-0740-27,NDC,outpatient,0.6,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,99999-0003-45,NDC,outpatient,0.6,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-73,NDC,outpatient,20,ML,14.91,10.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-83,NDC,outpatient,20,ML,14.91,10.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-00,NDC,outpatient,100,ML,36.05,25.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-04,NDC,outpatient,100,ML,36.05,25.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-02,NDC,outpatient,5,ML,19.45,13.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,63323-0083-05,NDC,outpatient,5,ML,33.6,23.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-14,NDC,outpatient,10,ML,57.94,40.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-24,NDC,outpatient,10,ML,57.94,40.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-12,NDC,outpatient,5,ML,19.45,13.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-14,NDC,outpatient,50,ML,85.67,59.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-24,NDC,outpatient,50,ML,85.67,59.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-14,NDC,outpatient,50,ML,35.83,25.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-14,NDC,outpatient,50,ML,54.74,38.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-04,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,63323-0089-50,NDC,outpatient,50,ML,24.7,17.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-24,NDC,outpatient,10,ML,71.78,50.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-22,NDC,outpatient,50,ML,35.83,25.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-14,NDC,outpatient,10,ML,71.78,50.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,69374-0214-50,NDC,outpatient,50,ML,48.95,34.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-24,NDC,outpatient,50,ML,54.74,38.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-01,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,76329-3352-01,NDC,outpatient,50,ML,66.31,46.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM BICARBONATE 650 MG ORAL TABS,RX-7313,CDM,S5000,HCPCS,259,RC,66553-0008-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,00338-0054-03,NDC,outpatient,500,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,99999-0004-11,NDC,outpatient,250,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-02,NDC,outpatient,100,ML,55.63,38.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-61,NDC,outpatient,100,ML,55.63,38.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-03,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-33,NDC,outpatient,3,ML,1.13,0.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,76204-0300-03,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,50190-0142-63,NDC,outpatient,4,ML,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,00487-9003-30,NDC,outpatient,4,ML,2.44,1.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-25,NDC,outpatient,1,UN,1.03,0.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,00223-1760-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-10,NDC,outpatient,1,UN,1.03,0.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,S5000,HCPCS,259,RC,24208-0385-55,NDC,outpatient,3.5,GR,68.8,48.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,S5000,HCPCS,259,RC,00536-1254-94,NDC,outpatient,15,ML,15.76,11.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM HYPOCHLORITE 5 % SOLN,RX-7343,CDM,S5000,HCPCS,259,RC,SH000-4343-01,NDC,outpatient,4000,ML,17.8,12.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM POLYSTYRENE SULFONATE ORAL POWD,RX-7356,CDM,S5000,HCPCS,259,RC,11534-0166-15,NDC,outpatient,15,GR,55.61,38.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFACETAMIDE SODIUM 10 % OP SOLN,RX-7359,CDM,S5000,HCPCS,259,RC,24208-0670-04,NDC,outpatient,15,ML,213.67,149.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,S5000,HCPCS,259,RC,60219-1749-03,NDC,outpatient,5,ML,103.02,72.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,00904-6927-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,63629-1061-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-24,NDC,outpatient,50,ML,8.74,6.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-01,NDC,outpatient,10,ML,4.79,3.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-10,NDC,outpatient,10,ML,4.22,2.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-50,NDC,outpatient,50,ML,8.74,6.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-25,NDC,outpatient,10,ML,4.79,3.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0003-47,NDC,outpatient,3000,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0004-04,NDC,outpatient,1000,ML,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
STOMAHESIVE PASTE PSTE,RX-7493,CDM,S5000,HCPCS,259,RC,68455-0106-90,NDC,outpatient,56.7,GR,38.61,27.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFADIAZINE 500 MG ORAL TABS,RX-7554,CDM,S5000,HCPCS,259,RC,42806-0757-60,NDC,outpatient,1,UN,65.91,46.137,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-01,NDC,outpatient,10,ML,27.51,19.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-10,NDC,outpatient,10,ML,27.51,19.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-03,NDC,outpatient,10,ML,28.26,19.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-01,NDC,outpatient,10,ML,28.26,19.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-15,NDC,outpatient,1,UN,1.12,0.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-11,NDC,outpatient,1,UN,1.12,0.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-65,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-11,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFASALAZINE 500 MG ORAL TABS,RX-7562,CDM,S5000,HCPCS,259,RC,59762-5000-05,NDC,outpatient,1,UN,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,00013-0102-50,NDC,outpatient,1,UN,8.65,6.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,59762-0104-05,NDC,outpatient,1,UN,1.47,1.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VARENICLINE TARTRATE 0.5 MG ORAL TABS,RX-76444,CDM,S5000,HCPCS,259,RC,49884-0155-76,NDC,outpatient,1,UN,6.79,4.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-21,NDC,outpatient,1,UN,43.68,30.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-11,NDC,outpatient,1,UN,43.68,30.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,S5000,HCPCS,259,RC,24208-0539-20,NDC,outpatient,1,UN,349.11,244.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,00436-0672-16,NDC,outpatient,473,ML,52.63,36.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,39328-0064-12,NDC,outpatient,473,ML,44.21,30.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-40,NDC,outpatient,15,ML,19.43,13.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-50,NDC,outpatient,15,ML,8.75,6.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-15,NDC,outpatient,15,ML,3.54,2.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-16,NDC,outpatient,7.5,ML,2.05,1.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-15,NDC,outpatient,15,ML,19.43,13.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-01,NDC,outpatient,15,ML,8.75,6.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN D3 25 MCG (1000 UT) ORAL TABS,RX-76997,CDM,S5000,HCPCS,259,RC,20555-0033-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TANNIC ACID POWD,RX-7715,CDM,S5000,HCPCS,259,RC,,,outpatient,20,GR,9.26,6.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-05,NDC,outpatient,10,ML,230.25,161.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-01,NDC,outpatient,10,ML,230.25,161.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-01,NDC,outpatient,1,UN,78.54,54.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-28,NDC,outpatient,1,UN,78.54,54.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-28,NDC,outpatient,1,UN,78.54,54.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-01,NDC,outpatient,1,UN,78.54,54.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-31,NDC,outpatient,1,UN,78.53,54.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,00121-1576-10,NDC,outpatient,10,ML,13.35,9.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,99999-0001-27,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,00065-0741-14,NDC,outpatient,4,ML,54.08,37.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,68682-0920-64,NDC,outpatient,15,ML,325.88,228.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TETRACYCLINE HCL 250 MG ORAL CAPS,RX-7796,CDM,S5000,HCPCS,259,RC,23155-0766-01,NDC,outpatient,1,UN,2.97,2.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-40,NDC,outpatient,15,ML,35.25,24.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-44,NDC,outpatient,15,ML,40.12,28.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-71,NDC,outpatient,15,ML,40.12,28.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-15,NDC,outpatient,15,ML,35.25,24.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THERA ORAL TABS,RX-7825,CDM,S5000,HCPCS,259,RC,00904-0539-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THERA-DERM EX LOTN,RX-7831,CDM,S5000,HCPCS,259,RC,00904-4299-09,NDC,outpatient,236,ML,8.41,5.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MESALAMINE 1.2 G ORAL TBEC,RX-78310,CDM,S5000,HCPCS,259,RC,00527-3012-48,NDC,outpatient,1,UN,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,49348-0011-34,NDC,outpatient,177,ML,6.31,4.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00395-0413-96,NDC,outpatient,177,ML,11.82,8.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00904-2533-21,NDC,outpatient,177,ML,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-05,NDC,outpatient,5,ML,11.06,7.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-40,NDC,outpatient,5,ML,11.06,7.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,99999-0002-04,NDC,outpatient,5,ML,1.78,1.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THYROID 30 MG ORAL TABS,RX-7944,CDM,S5000,HCPCS,259,RC,62559-0741-01,NDC,outpatient,1,UN,2.88,2.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,49348-0155-29,NDC,outpatient,15,GR,8.88,6.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,00904-0722-36,NDC,outpatient,14.18,GR,4.36,3.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,S5000,HCPCS,259,RC,00536-1329-26,NDC,outpatient,45,GR,7.41,5.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-11,NDC,outpatient,1,UN,1.77,1.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-15,NDC,outpatient,1,UN,1.77,1.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,68382-0807-01,NDC,outpatient,1,UN,1.31,0.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,50111-0560-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,60505-2653-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,00904-6868-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,68382-0805-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,S5000,HCPCS,259,RC,00168-0003-80,NDC,outpatient,80,GR,21.72,15.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,45802-0064-36,NDC,outpatient,80,GR,11.04,7.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,67877-0251-80,NDC,outpatient,80,GR,39.16,27.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,S5000,HCPCS,259,RC,45802-0065-35,NDC,outpatient,15,GR,20.23,14.161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN,RX-8115,CDM,S5000,HCPCS,259,RC,70752-0129-05,NDC,outpatient,60,ML,126.03,88.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,00713-0676-53,NDC,outpatient,60,ML,73.43,51.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,60432-0561-61,NDC,outpatient,60,ML,66.75,46.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.025 % EX OINT,RX-8117,CDM,S5000,HCPCS,259,RC,00168-0005-80,NDC,outpatient,80,GR,21.01,14.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,51672-1284-08,NDC,outpatient,80,GR,43.44,30.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00713-0228-80,NDC,outpatient,80,GR,37.03,25.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00168-0006-80,NDC,outpatient,80,GR,22.79,15.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,45802-0055-36,NDC,outpatient,80,GR,19.58,13.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,S5000,HCPCS,259,RC,33342-0332-15,NDC,outpatient,15,GR,28.77,20.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,S5000,HCPCS,259,RC,64980-0320-05,NDC,outpatient,5,GR,139.78,97.846,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIVALPROEX SODIUM ER 500 MG ORAL TB24,RX-81426,CDM,S5000,HCPCS,259,RC,00904-7182-45,NDC,outpatient,1,UN,11.3,7.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00186-0372-28,NDC,outpatient,6.9,GR,250.86,175.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00310-7372-20,NDC,outpatient,10.2,GR,973.53,681.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00186-0370-28,NDC,outpatient,6,GR,250.85,175.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00310-7370-20,NDC,outpatient,10.2,GR,1011.48,708.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIFLUOPERAZINE HCL 1 MG ORAL TABS,RX-8161,CDM,S5000,HCPCS,259,RC,00781-8028-01,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIFLUOPERAZINE HCL 5 MG ORAL TABS,RX-8164,CDM,S5000,HCPCS,259,RC,00781-8034-01,NDC,outpatient,1,UN,4.68,3.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,00591-5335-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,69452-0241-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TRIHEXYPHENIDYL HCL 5 MG ORAL TABS,RX-8167,CDM,S5000,HCPCS,259,RC,70954-0211-10,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,68180-0407-03,NDC,outpatient,6.25,ML,50.07,35.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,99999-0002-91,NDC,outpatient,6.25,ML,120.07,84.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0070-30,NDC,outpatient,37.5,GR,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-30,NDC,outpatient,37.5,GR,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-15,NDC,outpatient,37.5,GR,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0626-53,NDC,outpatient,31,GR,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0627-63,NDC,outpatient,31,GR,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0207-60,NDC,outpatient,4,ML,3.01,2.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0307-60,NDC,outpatient,4,ML,1.2,0.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,50190-0141-23,NDC,outpatient,4,ML,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THROMBI-GEL 40 EX PADS,RX-82259,CDM,S5000,HCPCS,259,RC,60793-0908-04,NDC,outpatient,1,UN,254.02,177.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TROPICAMIDE 1 % OP SOLN,RX-8250,CDM,S5000,HCPCS,259,RC,70069-0121-01,NDC,outpatient,15,ML,25.3,17.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-15,NDC,outpatient,1,UN,93.94,65.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-61,NDC,outpatient,1,UN,93.94,65.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-11,NDC,outpatient,1,UN,24.46,17.122,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-03,NDC,outpatient,1,UN,24.46,17.122,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-21,NDC,outpatient,0.1,ML,35.98,25.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-78,NDC,outpatient,0.1,ML,35.98,25.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
UNNA-FLEX ELASTIC UNNA BOOT EX MISC,RX-8371,CDM,S5000,HCPCS,250,RC,68455-0107-63,NDC,outpatient,1,UN,44.16,30.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,69452-0150-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00832-0310-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00591-4012-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT,RX-849,CDM,S5000,HCPCS,259,RC,24208-0785-55,NDC,outpatient,3.5,GR,70.76,49.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-01,NDC,outpatient,2,ML,15.45,10.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-02,NDC,outpatient,2,ML,15.45,10.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-04,NDC,outpatient,2,ML,15.45,10.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,70710-1643-07,NDC,outpatient,2,ML,44.5,31.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL 120 MG ORAL TABS,RX-8528,CDM,S5000,HCPCS,259,RC,23155-0486-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL 40 MG ORAL TABS,RX-8529,CDM,S5000,HCPCS,259,RC,23155-0059-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VERAPAMIL HCL 80 MG ORAL TABS,RX-8530,CDM,S5000,HCPCS,259,RC,23155-0026-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,49348-0029-72,NDC,outpatient,30,GR,11.49,8.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,70677-0013-01,NDC,outpatient,28.4,GR,10.49,7.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,S5000,HCPCS,259,RC,00501-3798-05,NDC,outpatient,14.2,GR,20.67,14.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,S5000,HCPCS,259,RC,24208-0555-55,NDC,outpatient,3.5,GR,22.88,16.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00527-1330-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,63739-0479-10,NDC,outpatient,1,UN,1.74,1.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00904-6475-61,NDC,outpatient,1,UN,1.6,1.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN E 100 UNITS ORAL CAPS,RX-8698,CDM,S5000,HCPCS,259,RC,80681-0134-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,00536-1352-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-05,NDC,outpatient,5,GR,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-14,NDC,outpatient,5,GR,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-01,NDC,outpatient,1,UN,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-11,NDC,outpatient,1,UN,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-01,NDC,outpatient,1,UN,1.29,0.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-11,NDC,outpatient,1,UN,1.29,0.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0205-05,NDC,outpatient,1,UN,228.51,159.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0705-05,NDC,outpatient,1,UN,217.65,152.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,S5000,HCPCS,259,RC,35181-7303-32,NDC,outpatient,25,GR,146.52,102.564,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,82182-0455-05,NDC,outpatient,5,ML,356.54,249.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,00023-9211-05,NDC,outpatient,5,ML,838.92,587.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZEPAM 2.5 MG RE GEL,RX-87865,CDM,S5000,HCPCS,259,RC,68682-0650-20,NDC,outpatient,1,UN,430.63,301.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZEPAM 10 MG RE GEL,RX-87867,CDM,S5000,HCPCS,259,RC,68682-0652-20,NDC,outpatient,1,UN,622.96,436.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DIAZEPAM 20 MG RE GEL,RX-87869,CDM,S5000,HCPCS,259,RC,68682-0655-20,NDC,outpatient,1,UN,601.24,420.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-06,NDC,outpatient,2,ML,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-01,NDC,outpatient,2,ML,18.21,12.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-19,NDC,outpatient,2,ML,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-32,NDC,outpatient,2,ML,38.15,26.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,49502-0605-61,NDC,outpatient,2,ML,20.29,14.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-93,NDC,outpatient,2,ML,38.15,26.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-60,NDC,outpatient,2,ML,18.21,12.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-44,NDC,outpatient,2,ML,11.64,8.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-60,NDC,outpatient,2,ML,11.64,8.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RALTEGRAVIR POTASSIUM 400 MG ORAL TABS,RX-88608,CDM,S5000,HCPCS,259,RC,00006-0227-61,NDC,outpatient,1,UN,143.66,100.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-11,NDC,outpatient,10,ML,63.68,44.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-01,NDC,outpatient,10,ML,63.68,44.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,00004-0802-85,NDC,outpatient,1,UN,57.3,40.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,31722-0630-31,NDC,outpatient,1,UN,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OSELTAMIVIR PHOSPHATE 45 MG ORAL CAPS,RX-88705,CDM,S5000,HCPCS,259,RC,00004-0801-85,NDC,outpatient,1,UN,57.3,40.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,00536-1316-98,NDC,outpatient,454,GR,22.23,15.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,75834-0170-01,NDC,outpatient,28.4,GR,13.53,9.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-01,NDC,outpatient,10,ML,75.92,53.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-25,NDC,outpatient,10,ML,75.92,53.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-01,NDC,outpatient,5,ML,189.8,132.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-25,NDC,outpatient,5,ML,189.8,132.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-59,NDC,outpatient,1,UN,6.38,4.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,00904-6707-82,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-64,NDC,outpatient,1,UN,6.38,4.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
NEBIVOLOL HCL 5 MG ORAL TABS,RX-89284,CDM,S5000,HCPCS,259,RC,00904-7189-04,NDC,outpatient,1,UN,7.99,5.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-07,NDC,outpatient,1,UN,32.67,22.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-10,NDC,outpatient,1,UN,22.14,15.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-15,NDC,outpatient,1,UN,5.16,3.612,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-11,NDC,outpatient,1,UN,5.16,3.612,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,57074-0001-86,NDC,outpatient,60,GR,9.35,6.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,30103-0040-00,NDC,outpatient,60,GR,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-61,NDC,outpatient,5,ML,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-00,NDC,outpatient,5,ML,4.72,3.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-05,NDC,outpatient,5,ML,4.72,3.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-59,NDC,outpatient,5,ML,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-62,NDC,outpatient,5,ML,2.76,1.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,99999-0004-23,NDC,outpatient,5,ML,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,60219-1721-07,NDC,outpatient,1,UN,36.43,25.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,59676-0570-01,NDC,outpatient,1,UN,53.89,37.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-23,NDC,outpatient,1,UN,1.51,1.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-62,NDC,outpatient,1,UN,1.51,1.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,S5000,HCPCS,250,RC,00338-0322-01,NDC,outpatient,1,UN,281.38,196.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00527-1695-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00904-6938-06,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-65,NDC,outpatient,1,UN,4.66,3.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,10702-0253-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-11,NDC,outpatient,1,UN,4.66,3.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACETIC ACID 0.25 % IR SOLN,RX-8963,CDM,S5000,HCPCS,250,RC,00338-0656-04,NDC,outpatient,1000,ML,13.35,9.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,00187-0994-45,NDC,outpatient,5,GR,822.36,575.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,45802-0044-75,NDC,outpatient,5,GR,210.13,147.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,00904-5789-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,60505-0042-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,31722-0681-47,NDC,outpatient,473,ML,244.17,170.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,99999-0004-02,NDC,outpatient,5,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,00472-0082-16,NDC,outpatient,473,ML,1582.85,1107.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-11,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-01,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,57896-0629-12,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-30,NDC,outpatient,30,ML,1.7,1.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,99999-0002-58,NDC,outpatient,30,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00121-1761-30,NDC,outpatient,30,ML,7.21,5.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-73,NDC,outpatient,30,ML,11.09,7.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-62,NDC,outpatient,30,ML,11.09,7.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-01,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMINOCAPROIC ACID 500 MG ORAL TABS,RX-9063,CDM,S5000,HCPCS,259,RC,69680-0115-30,NDC,outpatient,1,UN,26.56,18.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,63739-0051-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00904-6993-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMLODIPINE BESYLATE 2.5 MG ORAL TABS,RX-9070,CDM,S5000,HCPCS,259,RC,00904-6369-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,68382-0122-16,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,00904-6370-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,64850-0502-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,42806-0341-01,NDC,outpatient,1,UN,1.52,1.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00591-3659-30,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00008-1211-14,NDC,outpatient,1,UN,5.76,4.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,51991-0311-90,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ROPINIROLE HCL ER 2 MG ORAL TB24,RX-92015,CDM,S5000,HCPCS,259,RC,55111-0659-30,NDC,outpatient,1,UN,2.69,1.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-11,NDC,outpatient,1,UN,2.09,1.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-15,NDC,outpatient,1,UN,2.09,1.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,S5000,HCPCS,259,RC,61314-0245-01,NDC,outpatient,5,ML,147.74,103.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10135-0623-01,NDC,outpatient,1,UN,2.28,1.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10702-0013-01,NDC,outpatient,1,UN,1.58,1.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
MOUTH KOTE MT SOLN,RX-92764,CDM,S5000,HCPCS,259,RC,50930-0098-02,NDC,outpatient,59,ML,21.53,15.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BROMOCRIPTINE MESYLATE 2.5 MG ORAL TABS,RX-9297,CDM,S5000,HCPCS,259,RC,00574-0106-03,NDC,outpatient,1,UN,3.28,2.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-11,NDC,outpatient,1,UN,5.55,3.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,42799-0119-01,NDC,outpatient,1,UN,1.43,1.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-15,NDC,outpatient,1,UN,5.55,3.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-11,NDC,outpatient,1,UN,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-05,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-11,NDC,outpatient,1,UN,3.09,2.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-01,NDC,outpatient,1,UN,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,69238-1490-01,NDC,outpatient,1,UN,1.61,1.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-15,NDC,outpatient,1,UN,3.09,2.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-57,NDC,outpatient,50,ML,49.4,34.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-01,NDC,outpatient,50,ML,49.4,34.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL 100 MG ORAL TABS,RX-9321,CDM,S5000,HCPCS,259,RC,00904-6636-61,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-11,NDC,outpatient,1,UN,2.99,2.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-15,NDC,outpatient,1,UN,2.99,2.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-01,NDC,outpatient,1,UN,3.85,2.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-11,NDC,outpatient,1,UN,3.85,2.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00904-7122-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00093-0053-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,69452-0207-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,23155-0662-01,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,66553-0004-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,00904-6412-92,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-32,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-33,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SORBITOL 70 % SOLN,RX-93927,CDM,S5000,HCPCS,259,RC,46287-0500-30,NDC,outpatient,30,ML,9.48,6.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-93,NDC,outpatient,3,ML,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-03,NDC,outpatient,3,ML,1.13,0.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,76204-0600-01,NDC,outpatient,3,ML,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-31,NDC,outpatient,3,ML,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-01,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-48,NDC,outpatient,3,ML,1.42,0.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-49,NDC,outpatient,3,ML,1.42,0.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-30,NDC,outpatient,3,ML,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-60,NDC,outpatient,3,ML,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAPTOPRIL 12.5 MG ORAL TABS,RX-9401,CDM,S5000,HCPCS,259,RC,00904-7105-61,NDC,outpatient,1,UN,6.29,4.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CAPTOPRIL 25 MG ORAL TABS,RX-9402,CDM,S5000,HCPCS,259,RC,00904-7106-61,NDC,outpatient,1,UN,5.2,3.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBIDOPA-LEVODOPA 10-100 MG ORAL TABS,RX-9406,CDM,S5000,HCPCS,259,RC,00093-9701-01,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,00093-9702-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-05,NDC,outpatient,1,ML,319.49,223.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-08,NDC,outpatient,1,ML,319.49,223.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,S5000,HCPCS,259,RC,00904-6255-49,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,60258-0162-01,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,63044-0622-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFACLOR 250 MG ORAL CAPS,RX-9430,CDM,S5000,HCPCS,259,RC,61442-0171-30,NDC,outpatient,1,UN,8.1,5.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-01,NDC,outpatient,1,UN,2.36,1.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,16714-0388-01,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,65862-0085-50,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-08,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,00781-5439-20,NDC,outpatient,1,UN,12.33,8.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,65862-0096-20,NDC,outpatient,1,UN,14.53,10.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,16714-0400-02,NDC,outpatient,1,UN,3.64,2.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,67877-0215-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,65862-0699-60,NDC,outpatient,1,UN,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-15,NDC,outpatient,1,UN,1.49,1.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-01,NDC,outpatient,1,UN,1.3,0.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-11,NDC,outpatient,1,UN,1.49,1.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-11,NDC,outpatient,1,UN,1.3,0.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,67877-0220-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-15,NDC,outpatient,15,ML,6.55,4.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-19,NDC,outpatient,15,ML,6.15,4.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,1,ML,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,5.99,4.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,99999-0003-94,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,54838-0011-50,NDC,outpatient,50,ML,14.02,9.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,69315-0308-05,NDC,outpatient,5,ML,62.3,43.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,61314-0656-05,NDC,outpatient,5,ML,15.4,10.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,00527-1931-06,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,65862-0225-60,NDC,outpatient,1,UN,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,00168-0202-30,NDC,outpatient,30,GR,207.33,145.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,59762-3743-01,NDC,outpatient,30,GR,208.26,145.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,51672-1258-02,NDC,outpatient,30,GR,31.11,21.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,69238-1532-05,NDC,outpatient,15,GR,19.83,13.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,51672-1259-02,NDC,outpatient,30,GR,43.53,30.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,21922-0017-05,NDC,outpatient,30,GR,42.19,29.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-25,NDC,outpatient,1,UN,36.81,25.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-95,NDC,outpatient,1,UN,36.81,25.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-11,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,16729-0137-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-11,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,43547-0407-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00054-4146-22,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00574-0107-70,NDC,outpatient,1,UN,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-01,NDC,outpatient,1,UN,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-01,NDC,outpatient,1,UN,4.21,2.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-11,NDC,outpatient,1,UN,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-20,NDC,outpatient,1,UN,4.21,2.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-20,NDC,outpatient,1,UN,2.14,1.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-01,NDC,outpatient,1,UN,2.14,1.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,S5000,HCPCS,259,RC,50484-0010-30,NDC,outpatient,30,GR,1218.46,852.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,S5000,HCPCS,259,RC,61314-0237-10,NDC,outpatient,10,ML,27.77,19.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-60,NDC,outpatient,1,UN,53.28,37.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-35,NDC,outpatient,1,UN,48.43,33.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,68462-0678-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,00131-2478-60,NDC,outpatient,1,UN,83.29,58.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,31722-0813-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-57,NDC,outpatient,1,UN,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,51991-0349-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-11,NDC,outpatient,1,UN,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,S5000,HCPCS,259,RC,00065-0397-02,NDC,outpatient,2,ML,180.67,126.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,S5000,HCPCS,259,RC,00065-0359-02,NDC,outpatient,2,ML,144.23,100.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-61,NDC,outpatient,1,UN,74.28,51.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-15,NDC,outpatient,1,UN,74.28,51.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,60505-0134-00,NDC,outpatient,1,UN,46.97,32.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-25,NDC,outpatient,1,UN,18.44,12.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-95,NDC,outpatient,1,UN,18.44,12.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-61,NDC,outpatient,1,UN,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-15,NDC,outpatient,1,UN,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,S5000,HCPCS,250,RC,42023-0123-06,NDC,outpatient,1,UN,288.51,201.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00115-4411-01,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00904-7211-04,NDC,outpatient,1,UN,4.53,3.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,55150-0173-01,NDC,outpatient,0.5,ML,17.69,12.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,63323-0273-01,NDC,outpatient,0.5,ML,24.66,17.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,99999-0002-38,NDC,outpatient,10,ML,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,60432-0608-16,NDC,outpatient,10,ML,3.48,2.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-10,NDC,outpatient,10,ML,7.53,5.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00904-7135-72,NDC,outpatient,10,ML,6.5,4.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-34,NDC,outpatient,118,ML,8.93,6.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-00,NDC,outpatient,10,ML,7.53,5.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-10,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-04,NDC,outpatient,118,ML,17.33,12.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-10,NDC,outpatient,10,ML,1.7,1.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,99999-0001-87,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
TOLVAPTAN 15 MG ORAL TABS,RX-97893,CDM,S5000,HCPCS,259,RC,59148-0020-50,NDC,outpatient,1,UN,1428.57,999.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS ORAL CPEP,RX-98034,CDM,S5000,HCPCS,259,RC,00032-0046-70,NDC,outpatient,1,UN,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-2636-01,NDC,outpatient,1,UN,33.86,23.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-1224-01,NDC,outpatient,1,UN,33.86,23.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN,RX-9809,CDM,S5000,HCPCS,250,RC,00264-7622-00,NDC,outpatient,1000,ML,51.6,36.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-9812,CDM,S5000,HCPCS,250,RC,00338-0077-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE-SODIUM CHLORIDE 5-0.33 % IV SOLN,RX-9813,CDM,S5000,HCPCS,250,RC,00264-7614-10,NDC,outpatient,500,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DRONEDARONE HCL 400 MG ORAL TABS,RX-98329,CDM,S5000,HCPCS,259,RC,00024-4142-60,NDC,outpatient,1,UN,53.6,37.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRASUGREL HCL 5 MG ORAL TABS,RX-98372,CDM,S5000,HCPCS,259,RC,60505-4642-03,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,1,UN,4.12,2.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,1,UN,2.9,2.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,1,UN,1,0.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZOIN COMPOUND EX TINC,RX-987,CDM,S5000,HCPCS,259,RC,00395-0243-92,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DINOPROSTONE 0.5 MG/3GM VA GEL,RX-9874,CDM,S5000,HCPCS,259,RC,00009-3359-01,NDC,outpatient,3,GR,1932.45,1352.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,00904-7153-61,NDC,outpatient,1,UN,1.32,0.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,64380-0712-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,42806-0714-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,69452-0143-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,00904-5522-61,NDC,outpatient,1,UN,2.36,1.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-95,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-25,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,00904-5524-61,NDC,outpatient,1,UN,2.28,1.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,16729-0213-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,60505-0095-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,68180-0657-01,NDC,outpatient,20,ML,27.06,18.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,99999-0002-89,NDC,outpatient,20,ML,27.06,18.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,S5000,HCPCS,259,RC,51672-1303-01,NDC,outpatient,15,GR,32.65,22.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,23155-0772-01,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,43547-0547-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENALAPRIL MALEATE 2.5 MG ORAL TABS,RX-9925,CDM,S5000,HCPCS,259,RC,16714-0442-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-10,NDC,outpatient,2,ML,34.39,24.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-01,NDC,outpatient,2,ML,34.39,24.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,99999-0002-24,NDC,outpatient,0.6,ML,13.98,9.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,42799-0217-01,NDC,outpatient,0.6,ML,13.98,9.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GLYCERIN (LAXATIVE) 1 G RE SUPP,RX-99417,CDM,S5000,HCPCS,259,RC,58980-0409-12,NDC,outpatient,1,UN,2.17,1.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0162-88,NDC,outpatient,1,UN,133.64,93.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0146-19,NDC,outpatient,1,UN,133.73,93.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ESTROGENS CONJUGATED 0.3 MG ORAL TABS,RX-9973,CDM,S5000,HCPCS,259,RC,00046-1100-81,NDC,outpatient,1,UN,28.4,19.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,42023-0157-01,NDC,outpatient,1,UN,1563.3,1094.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,67457-0297-50,NDC,outpatient,1,UN,2098.98,1469.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-11,NDC,outpatient,1,UN,1.82,1.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-01,NDC,outpatient,1,UN,1.82,1.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETHACRYNIC ACID 25 MG ORAL TABS,RX-9980,CDM,S5000,HCPCS,259,RC,69238-1126-01,NDC,outpatient,1,UN,8.7,6.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETHAMBUTOL HCL 400 MG ORAL TABS,RX-9983,CDM,S5000,HCPCS,259,RC,68850-0012-02,NDC,outpatient,1,UN,3.21,2.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,24979-0533-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,60505-3927-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
GUANFACINE HCL ER 2 MG ORAL TB24,RX-99836,CDM,S5000,HCPCS,259,RC,62332-0746-31,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,23155-0532-01,NDC,outpatient,1,UN,5.34,3.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,64380-0878-06,NDC,outpatient,1,UN,1.63,1.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-01,NDC,outpatient,1,UN,1.62,1.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-11,NDC,outpatient,1,UN,1.62,1.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,60505-0039-01,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,62559-0250-01,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
ETODOLAC 300 MG ORAL CAPS,RX-9998,CDM,S5000,HCPCS,259,RC,62559-0251-01,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates
HC Crisis Intervention Mental Health Services- per Diem,PX-90000001,CDM,S9485,HCPCS,900,RC,,,outpatient,,,1627,1138.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,741.66,,,741.66,365.2615,1249.536,fee schedule,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,outpatient,,,10370,7259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8789.61,399.86,9291.52,percent of total billed charges,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,outpatient,,,7029,4920.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5957.78,399.86,9291.52,percent of total billed charges,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions 
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1774.62,399.86,2223.8905,percent of total billed charges,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3992.7552,other,SI=N Exclusions 
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3992.7552,other,SI=N Exclusions 
Bilateral procedure,,,,,,,,,,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,525.9295,1261.6,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,808.0705,1938.4,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,731.3655,1754.4,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1108.2205,2658.4,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2425.01,,,2425.01,594.6305,2483,per diem,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,444.5555,1066.4,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,398.5325,956,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1337.0015,3207.2,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1215.941,2916.8,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,672.0025,1612,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1604.135,3848,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.205,72,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.491,94.4,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.3685,90.4,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.96,64,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.7355,63.2,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,59.9415,213.6,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.205,72,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.309,225.6,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.166,214.4,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.5335,226.4,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.9825,228,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,64.4315,229.6,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,68.9215,245.6,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,94.9635,338.4,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,98.331,350.4,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,118.7605,423.2,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,118.7605,423.2,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,183.192,652.8,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,871.958,3107.2,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1098.0295,3912.8,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1176.829,4193.6,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1227.117,4372.8,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,149.7415,533.6,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.2485,282.4,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,73.4115,261.6,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,87.555,312,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,158.7215,565.6,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,32.328,122.0544,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,58.819,222.0712,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,61.064,230.5472,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,68.697,259.3656,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,84.6365,319.5452,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,105.7395,399.2196,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.005,415.324,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,210.8055,795.8964,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.756,74.5888,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.3275,80.522,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.246,91.5408,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,28.736,108.4928,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,43.3285,163.5868,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,43.7775,165.282,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,50.5125,190.71,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.1465,302.5932,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.1465,302.5932,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.1465,302.5932,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,83.963,317.0024,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,88.902,335.6496,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,90.249,340.7352,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,91.8205,346.6684,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,93.841,354.2968,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,93.6165,353.4492,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.127,378.0296,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,101.2495,382.2676,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,104.617,394.9816,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,104.617,394.9816,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,105.515,398.372,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.556,413.6288,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,115.842,437.3616,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,116.5155,439.9044,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,117.4135,443.2948,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,121.4545,458.5516,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,121.4545,458.5516,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,124.822,471.2656,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,151.313,571.2824,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.803,588.2344,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.803,588.2344,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.803,588.2344,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.8235,595.8628,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,161.4155,609.4244,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,162.089,611.9672,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,164.1095,619.5956,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,171.7425,648.414,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.212,657.7376,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.212,657.7376,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,189.7025,716.222,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,189.7025,716.222,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,189.7025,716.222,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.9275,758.602,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.9275,758.602,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,185.6615,700.9652,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,210.8055,795.8964,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,219.7855,829.8004,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,354.9345,1340.0556,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,354.9345,1340.0556,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,255.032,962.8736,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,284.8905,1075.6044,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,296.1155,1117.9844,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,314.0755,1185.7924,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,316.096,1193.4208,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,455.0615,1718.0852,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,498.1655,1880.8244,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,584.149,2205.4552,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,660.7035,2494.4868,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1249.3425,4716.894,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1237.444,4671.9712,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,924.94,3492.112,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1237.444,4671.9712,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,302.8505,1143.4124,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.7555,33.0564,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,277.931,1049.3288,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,249.8685,943.3788,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,423.6315,1599.4212,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,246.2765,929.8172,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,337.648,1274.7904,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,71.6155,270.3844,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,103.719,391.5912,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,241.7865,912.8652,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.107,411.9336,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.3515,378.8772,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,299.034,1129.0032,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,66.6765,251.7372,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,120.5565,455.1612,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,126.8425,478.894,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,93.6165,353.4492,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,92.494,349.2112,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.1295,585.6916,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,113.597,428.8856,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,95.188,359.3824,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,133.353,503.4744,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,118.7605,448.3804,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,203.397,767.9256,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.476,549.2448,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,222.255,839.124,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,194.1925,733.174,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,97.2085,367.0108,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,88.453,333.9544,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,136.047,513.6456,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.15,593.32,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,495.0225,1868.958,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,299.932,1132.3936,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,245.603,927.2744,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,266.706,1006.9488,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,259.073,978.1304,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,259.073,978.1304,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,176.2325,665.366,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.8855,660.2804,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,267.3795,1009.4916,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,220.6835,833.1908,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,102.5965,387.3532,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,105.7395,399.2196,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,104.3925,394.134,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,184.7635,697.5748,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,138.9655,524.6644,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,178.4775,673.842,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,162.089,611.9672,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,55.0025,207.662,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,214.173,808.6104,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,259.073,978.1304,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,111.5765,421.2572,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,56.3495,212.7476,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,91.596,345.8208,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.3515,378.8772,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.5955,304.2884,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.044,264.4512,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.044,264.4512,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,139.639,527.2072,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,123.924,467.8752,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,274.1145,1034.9196,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,846.814,3197.1472,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,438.673,1656.2104,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,854.447,3225.9656,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,148.3945,560.2636,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.965,483.132,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.965,483.132,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,759.9325,2869.126,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,715.0325,2699.606,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,85.31,322.088,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.8855,660.2804,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,74.085,279.708,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,85.759,323.7832,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.576,379.7248,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.1885,400.9148,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.699,425.4952,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,147.721,557.7208,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,148.3945,560.2636,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.8235,595.8628,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,167.2525,631.462,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,176.2325,665.366,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,202.2745,763.6876,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,205.4175,775.554,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,250.7665,946.7692,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,574.72,2169.856,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,574.72,2169.856,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,667.663,2520.7624,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,675.9695,2552.1236,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,675.9695,2552.1236,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,710.5425,2682.654,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,767.341,2897.0968,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,777.219,2934.3912,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1481.0265,5591.6172,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,147.721,557.7208,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,147.721,557.7208,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,276.584,1044.2432,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,392.875,1483.3,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,882.9585,3333.6108,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,923.593,3487.0264,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1001.4945,3781.1436,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,104.617,394.9816,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,667.663,2520.7624,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,667.663,2520.7624,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,667.663,2520.7624,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,238.419,900.1512,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,238.419,900.1512,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,238.419,900.1512,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,324.4025,1224.782,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.576,379.7248,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,77.9015,294.1172,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,239.0925,902.694,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.2485,299.2028,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,317.2185,1197.6588,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,289.605,1093.404,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,289.605,1093.404,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,479.3075,1809.626,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,167.2525,631.462,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,58.819,222.0712,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,58.819,222.0712,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.2485,299.2028,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,288.707,1090.0136,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.7005,550.0924,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,170.171,642.4808,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,238.6435,900.9988,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,245.3785,926.4268,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,273.2165,1031.5292,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,304.1975,1148.498,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,313.851,1184.9448,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,330.913,1249.3624,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,336.5255,1270.5524,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,398.0385,1502.7948,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,355.8325,1343.446,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,367.282,1386.6736,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,392.6505,1482.4524,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.413,401.7624,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.413,401.7624,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.413,401.7624,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,73.636,278.0128,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.107,411.9336,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,398.0385,1502.7948,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.803,588.2344,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.413,401.7624,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.6375,402.61,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,383.895,1449.396,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,297.9115,1124.7652,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,297.9115,1124.7652,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,291.85,1101.88,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.184,27.1232,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.879,120.3592,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,35.2465,133.0732,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.124,128.8352,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,46.696,176.3008,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.47,50.856,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.8375,63.57,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.47,50.856,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.8375,63.57,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2255,83.9124,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.43,118.664,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,30.981,116.9688,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,35.6955,134.7684,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.15,593.32,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,190.825,720.46,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,373.119,1408.7112,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,213.275,805.22,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,656.438,2478.3824,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,269.4,1017.12,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,956.819,3612.4712,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2057.767,7769.1016,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,269.4,1017.12,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,841.6505,3177.6524,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1202.422,4539.7456,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2164.4045,8171.7116,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.6125,21.19,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.939,18.6472,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.1635,19.4948,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.286,23.7328,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.5105,24.5804,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.4085,27.9708,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.531,32.2088,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,336.75,1271.4,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.83,,,104.83,22.6745,6652,per diem,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.7405,482.2844,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.7405,482.2844,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.5105,24.5804,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.5715,163,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.6535,163,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,38.3895,163,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9291.52,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6297.984,,
Heart Transplant Or Implant Of Heart Assist System With McC,1,MS-DRG,,,,,,,inpatient,,,509415.58,356590.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,570763.9296,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,495073.43,346551.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,434261.5728,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,347238.19,243066.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,286312.0824,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,111379.6,77965.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,109336.4384,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,80508.95,56356.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,90620.608,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,64638.3,45246.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,123186.8824,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,31748.36,22223.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,68016.116,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,38853.43,27197.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45091.4528,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,36305.14,25413.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32329.1856,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,66447.77,46513.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,78796.564,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,67076.27,46953.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,53661.016,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,60360.78,42252.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48288.624,,
Extracranial Procedures With McC,37,MS-DRG,,,,,,,inpatient,,,89958.63,62971.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71966.904,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,41578.78,29105.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33263.024,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,33795.18,23656.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,27036.144,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,68215.86,47751.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,54572.688,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,26930.4,18851.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30377.7624,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,21358.75,14951.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7123.143125,22105.9976,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,44783.08,31348.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50741.056,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,47305.96,33114.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37844.768,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,15006.39,10504.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5004.631065,37401.2648,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,24159.04,16911.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,24793.004,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,28159.44,19711.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6624.72,22527.552,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,89978.5,62984.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71982.8,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,41764.16,29234.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36086.1312,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,42817.54,29972.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34254.032,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,29171.68,20420.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40307.1224,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20113.63,14079.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6707.895605,20608.488,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,15729.11,11010.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5143.64,13947.7112,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,46442.5,32509.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37154,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,28051.55,19636.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6429.37,22441.24,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17263.03,12084.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5687.74,16215.2528,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,34983.65,24488.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35233.0168,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,19683.37,13778.359,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6564.403895,21354.2032,,
Nonspecific Cerebrovascular Disorders Without Cc/McC,72,MS-DRG,,,,,,,inpatient,,,12084.89,8459.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4030.310815,15200.0264,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,16388.09,11471.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5465.428015,31318.012,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,28055.14,19638.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7368.52,22444.112,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,26116.94,18281.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7097.19,20893.552,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,23235.5,16264.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7749.03925,31332.1968,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,15869.98,11108.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5292.63833,20219.4192,,
Hypertensive Encephalopathy Without Cc/McC,79,MS-DRG,,,,,,,inpatient,,,15211.5,10648.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5073.03525,13510.0088,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,53186.54,37230.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42549.232,,
Nontraumatic Stupor And Coma Without McC,81,MS-DRG,,,,,,,inpatient,,,72271.24,50589.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5585.72,57816.992,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,28572.47,20000.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47014.5064,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,30376.08,21263.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28173.0392,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,15324.04,10726.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5110.56734,19372.384,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,40898.43,28628.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45916.1976,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,13317.55,9322.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4441.402925,26578.2624,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,24255.02,16978.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6241.25,19404.016,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,42230.83,29561.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36937.2192,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,30155.68,21108.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7134.82,24124.544,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,16152.97,11307.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5387.015495,15994.3752,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,56481.63,39537.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,73931.1776,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,49973.83,34981.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,72642.3872,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,15617.77,10932.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5208.526295,43954.6424,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC,99,MS-DRG,,,,,,,inpatient,,,27081.74,18957.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28231.8048,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,34012.87,23809.009,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40228.0928,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,18803.33,13162.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6270.910555,18675.3024,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,27377.14,19163.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,23494.0816,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,23893.76,16725.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5992.35,19115.008,,
Acute Major Eye Infections With Cc/McC,121,MS-DRG,,,,,,,inpatient,,,20815.14,14570.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6941.84919,23569.0584,,
Acute Major Eye Infections Without Cc/McC,122,MS-DRG,,,,,,,inpatient,,,8234.57,5764.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2746.229095,13745.0712,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,28026.78,19618.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5537.24,22421.424,,
Other Disorders Of The Eye With McC Or Thrombolytic Agent,124,MS-DRG,,,,,,,inpatient,,,12298.33,8608.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4101.493055,26420.2032,,
Other Disorders Of The Eye Without McC,125,MS-DRG,,,,,,,inpatient,,,18740.93,13118.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6044.44,16731.9848,,
Mouth Procedures With Cc/McC,137,MS-DRG,,,,,,,inpatient,,,29533.69,20673.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28339.204,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,44941.05,31458.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,66905.6488,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,9316.44,6521.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3107.03274,35595.7424,,
Ear- Nose- Mouth And Throat Malignancy With McC,146,MS-DRG,,,,,,,inpatient,,,13156.92,9209.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4387.83282,46483.5896,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,13619.01,9533.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4541.939835,15147.34,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,14296.01,10007.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4767.719335,15360.112,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,12866.36,9006.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4290.93106,22993.5608,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,16420.88,11494.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5141.47,14421.8888,,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,12009,8406.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4005.0015,32953.3168,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,39912.51,27938.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6561.05,31930.008,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,11067.63,7747.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3691.054605,13625.5136,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,32953.66,23067.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33180.2736,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,27223.03,19056.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6432.99,21778.424,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,2839.79,1987.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,947.069965,13366.1344,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,115551.53,80886.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,93394.7496,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,85038.13,59526.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,68030.504,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,69826.08,48878.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,55860.864,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,55683.12,38978.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,78036.664,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,45649.7,31954.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37024.3544,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,47015.57,32910.899,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37612.456,,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,78265.02,54785.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,62612.016,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,20842.72,14589.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6951.04712,28554.0024,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,18317.47,12822.229,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6108.876245,16505.028,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,31259.62,21881.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32756.756,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,20969.38,14678.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6993.28823,20103.9144,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20162.41,14113.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6302.75,16129.928,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,37050.11,25935.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35415.3928,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,30930.47,21651.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,24744.376,,
Respiratory Neoplasms Without Cc/McC,182,MS-DRG,,,,,,,inpatient,,,24638.57,17246.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5697.87,19710.856,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,35855.45,25098.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32163.0208,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,22588.59,15812.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7520.46,21641.952,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,25741.06,18018.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32017.12,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,11443.72,8010.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3816.48062,20343.0296,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,21611.05,15127.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7207.285175,25076.7,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,22710.76,15897.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7574.03846,22762.5512,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,17567.6,12297.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5858.7946,17408.8024,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,13024.23,9116.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4343.580705,13114.8608,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,25981.01,18186.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26703.8992,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,18230.9,12761.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6080.00515,16616.48,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,12094.06,8465.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4033.36901,12620.4192,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25422.94,17796.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38181.4288,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,23032.67,16122.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7275.91,20059.3336,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,22301.78,15611.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7437.64363,35770.0128,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,31940.04,22358.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25552.032,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,17352.2,12146.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5133.51,13881.76,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,17596.96,12317.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5868.58616,19589.2088,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,12229.54,8560.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4078.55159,14109.8232,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,30544.64,21381.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5734.05,24435.712,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,23745.99,16622.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38252.3528,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,17630.01,12341.007,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5879.608335,18355.1312,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,173078.09,121154.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,138462.472,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,53859.21,37701.447,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,54390.6024,,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,inpatient,,,221306.62,154914.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,220737.7784,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,354301.39,248010.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,283441.112,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC,216,MS-DRG,,,,,,,inpatient,,,299760.69,209832.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,239808.552,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,inpatient,,,204620.11,143234.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,163696.088,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC,219,MS-DRG,,,,,,,inpatient,,,208854.44,146198.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,167083.552,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,inpatient,,,154365.68,108055.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,123492.544,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,181781.45,127247.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,145425.16,,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,228758.84,160131.188,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,183007.072,,
Other Cardiothoracic Procedures Without McC,229,MS-DRG,,,,,,,inpatient,,,95347.28,66743.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,76277.824,,
Coronary Bypass With Ptca With McC,231,MS-DRG,,,,,,,inpatient,,,220697.29,154488.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,176557.832,,
Coronary Bypass With Ptca Without McC,232,MS-DRG,,,,,,,inpatient,,,203083.55,142158.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,162466.84,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,193515.4,135460.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,158379.3712,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,165546.93,115882.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,132437.544,,
Coronary Bypass Without Cardiac Catheterization With McC,235,MS-DRG,,,,,,,inpatient,,,145342.16,101739.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,119229.3232,,
Coronary Bypass Without Cardiac Catheterization Without McC,236,MS-DRG,,,,,,,inpatient,,,130227.12,91158.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,104181.696,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,39344.02,27540.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,102059.636,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,41409.42,28986.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59008.768,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC,241,MS-DRG,,,,,,,inpatient,,,19499.72,13649.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6503.15662,30594.5872,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,76706.54,53694.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,68735.488,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,63602.84,44521.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50882.272,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,60755.43,42528.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48604.344,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,109531.23,76671.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,99020.036,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC,250,MS-DRG,,,,,,,inpatient,,,42609.28,29826.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46864.5528,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,52812.94,36969.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42250.352,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,100566.7,70396.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,80453.36,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,72499.37,50749.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,57999.496,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,68903.94,48232.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,55123.152,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13134.86,9194.402,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4380.47581,34319.1104,,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,20863.13,14604.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6957.853855,18073.4616,,
Cardiac Pacemaker Device Replacement With McC,258,MS-DRG,,,,,,,inpatient,,,71596.9,50117.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,57277.52,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,44827.64,31379.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35862.112,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,130030.35,91021.245,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,104024.28,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,49670.67,34769.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39736.536,,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC,262,MS-DRG,,,,,,,inpatient,,,58341.51,40839.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46673.208,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,49042.27,34329.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,70820.6536,,
Aicd Lead Procedures,265,MS-DRG,,,,,,,inpatient,,,64208.05,44945.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,72279.6616,,
Endovascular Cardiac Valve Replacement And Supplement Procedures With McC,266,MS-DRG,,,,,,,inpatient,,,134751.65,94326.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,121389.4656,,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC,267,MS-DRG,,,,,,,inpatient,,,133372.27,93360.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,106697.816,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,241728.99,169210.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,193383.192,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,132639.05,92847.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,106111.24,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,135782.35,95047.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,108625.88,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,140000.81,98000.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,112000.648,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,151532.98,106073.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,121226.384,,
Percutaneous And Other Intracardiac Procedures With McC,273,MS-DRG,,,,,,,inpatient,,,102782.81,71947.967,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,82226.248,,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,82201.95,57541.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,65761.56,,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,183325.52,128327.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,146660.416,,
Cardiac Defibrillator Implant With McC,276,MS-DRG,,,,,,,inpatient,,,196887.28,137821.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,157509.824,,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,177791.04,124453.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,142232.832,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,157626.97,110338.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,126101.576,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,93744.91,65621.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,74995.928,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31041.23,21728.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33263.356,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,26543.44,18580.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6744.11,21234.752,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,23815.3,16670.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5249.28,19052.24,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,19212.47,13448.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6407.358745,39624.2256,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,10954.07,7667.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3653.182345,15013.5976,,
Acute Myocardial Infarction- Expired Without Cc/McC,285,MS-DRG,,,,,,,inpatient,,,7163.26,5014.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2388.94721,11374.1832,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,38892.53,27224.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44850.3112,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,30727.74,21509.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,24582.192,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,28457.96,19920.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,55347.0632,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,19767.12,13836.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6592.33452,31948.2224,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,20727.01,14508.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6912.457835,26442.4936,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,15225.15,10657.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5077.587525,17453.3832,,
Heart Failure And Shock Without Cc/McC,293,MS-DRG,,,,,,,inpatient,,,10124.22,7086.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3376.42737,11124.936,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,25950.27,18165.189,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33198.5112,,
Cardiac Arrest- Unexplained With Cc,297,MS-DRG,,,,,,,inpatient,,,10642.36,7449.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3549.22706,14273.9616,,
Cardiac Arrest- Unexplained Without Cc/McC,298,MS-DRG,,,,,,,inpatient,,,12953.57,9067.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4151.065639,10362.856,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,22073.95,15451.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7361.662325,32781.0728,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,21942.88,15360.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7317.95048,21692.612,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,24649.73,17254.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5372.28,19719.784,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,9953.04,6967.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3319.33884,23571.0848,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16791.27,11753.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4894.02,13625.5136,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,37676.15,26373.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30140.92,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,16488.7,11542.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5343.34,15212.1848,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,22172.6,15520.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7394.5621,30343.3136,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,15582.95,10908.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5196.913825,18770.5432,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,19410.63,13587.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6473.445105,24438.384,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,14290.45,10003.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4765.865075,14981.1752,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,11407.4,7985.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3804.3679,11337.708,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,11897.35,8328.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3967.766225,14154.404,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,16541.17,11578.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5516.480195,17656.0232,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,15084.64,10559.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5030.72744,14454.3112,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,31164.15,21814.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43636.4976,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,18201.8,12741.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6070.3003,19500.0472,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,10045.09,7031.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3350.037515,13832.2064,,
Other Endovascular Cardiac Valve Procedures With McC,319,MS-DRG,,,,,,,inpatient,,,92577.92,64804.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,89009.62,,
Other Endovascular Cardiac Valve Procedures Without McC,320,MS-DRG,,,,,,,inpatient,,,39673.91,27771.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46903.0544,,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,92249.33,64574.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,73799.464,,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,75877.65,53114.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,60702.12,,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,116736.51,81715.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,93389.208,,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,126333.04,88433.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,101066.432,,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,inpatient,,,98701.5,69091.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,78961.2,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,64991.97,45494.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,102914.7768,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,59110.49,41377.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,49203.0184,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,49561.22,34692.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39648.976,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,78913.19,55239.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,93046.2088,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,69586.46,48710.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,55669.168,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,57546.85,40282.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46037.48,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,97325,68127.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,77860,,
Rectal Resection Without Cc/McC,334,MS-DRG,,,,,,,inpatient,,,106215.45,74350.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,84972.36,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,73034.84,51124.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,73434.7096,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,43630.89,30541.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42805.6736,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,37370.19,26159.133,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31105.24,,
Minor Small And Large Bowel Procedures With McC,344,MS-DRG,,,,,,,inpatient,,,23852.76,16696.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,54599.3216,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,15908.61,11136.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5305.521435,30177.1488,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,21216.99,14851.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7075.866165,25232.7328,,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,44922.74,31445.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47956.7824,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,23475.59,16432.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25508.3232,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,34354.1,24047.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30491.2408,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,42230.08,29561.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33784.064,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,312395.2,218676.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,249916.16,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,44235.04,30964.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35388.032,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,51507.45,36055.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,41205.96,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,70735.47,49514.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,86434.0656,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,77577.93,54304.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,62062.344,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,27080.24,18956.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,27457.72,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,23431.55,16402.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33838.8536,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,31489.94,22042.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25191.952,,
Major Esophageal Disorders Without Cc/McC,370,MS-DRG,,,,,,,inpatient,,,29793.71,20855.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5409.18,23834.968,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,37215.27,26050.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35427.5512,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,24764.87,17335.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7435.09,20857.7352,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,19807.89,13865.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5379.51,15846.312,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,38795.7,27156.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42787.436,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,40108.1,28075.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32086.48,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,8031.54,5622.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2678.51859,17891.0856,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,38252.31,26776.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36841.9784,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,30659.48,21461.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7186.19,24527.584,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,17080.5,11956.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4609.67,13664.4,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33361.1,23352.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38994.0152,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,34876.59,24413.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7667.34,27901.272,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,23295.58,16306.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6456.86,18636.464,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,19010.83,13307.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6340.111805,32922.9208,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,17687.57,12381.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5898.804595,20109.9936,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12268.03,8587.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4091.388005,13582.9592,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,35037.99,24526.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29788.08,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,19193.48,13435.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5946.04,16245.6488,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12403.72,8682.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4136.64062,11086.4344,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,23697.98,16588.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26037.2136,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16680.62,11676.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5530.73,15811.9992,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,35226.46,24658.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33555.1576,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,21027.93,14719.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6791.14,19074.5032,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,19292.51,13504.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4700.83,15434.008,,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,31379.86,21965.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50206.0864,,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,37379.45,26165.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30665.5112,,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,31865.55,22305.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25492.44,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,43167.44,30217.208,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,56905.3648,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,37981.98,26587.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43275.7984,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC,408,MS-DRG,,,,,,,inpatient,,,66496.81,46547.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,70946.2904,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,54723.42,38306.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43778.736,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC,410,MS-DRG,,,,,,,inpatient,,,49332.9,34533.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39466.32,,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,inpatient,,,94854.82,66398.374,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,75883.856,,
Cholecystectomy Except By Laparoscope Without C.D.E. With McC,414,MS-DRG,,,,,,,inpatient,,,158479.92,110935.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,126783.936,,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/McC,416,MS-DRG,,,,,,,inpatient,,,36054.28,25237.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28843.424,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,57775.9,40443.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48157.396,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,45650.74,31955.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36520.592,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,40583.9,28408.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32467.12,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,43141.15,30198.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71515.7088,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,126455.95,88519.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,101164.76,,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,inpatient,,,66431.87,46502.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,53145.496,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,37750.2,26425.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39699.2024,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,22206.74,15544.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7405.94779,21676.4008,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,9888.24,6921.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3297.72804,14111.8496,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41222.48,28855.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36971.668,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,21857.06,15299.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7289.32951,22849.6864,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,34142.65,23899.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33715.2432,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,18774.77,13142.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6109.56,17431.0928,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,12926.06,9048.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4310.84101,12464.3864,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,33617.1,23531.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38305.0392,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,18826.25,13178.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6278.554375,19579.0768,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,9263.58,6484.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3089.40393,14237.4864,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,36248.92,25374.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34134.708,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,33226.4,23258.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26581.12,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,28308.58,19816.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5905.53,22646.864,,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,114168.82,79918.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,91335.056,,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,93512.08,65458.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,74809.664,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With McC,456,MS-DRG,,,,,,,inpatient,,,202351.8,141646.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,171607.7104,,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,152088.75,106462.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,121671,,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,114206.41,79944.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,91365.128,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,70294.35,49206.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,109439.7848,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,25826.71,18078.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59750.4304,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,10589.98,7412.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3531.75833,35176.2776,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,134518.68,94163.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,107614.944,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,95919.47,67143.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,76735.576,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,68797.87,48158.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,55038.296,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,54280.26,37996.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,66232.884,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,53419.21,37393.447,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42735.368,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68987.67,48291.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,98422.248,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,77778.52,54444.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,62222.816,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,54869.65,38408.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47968.9408,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,71787.88,50251.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,90871.8816,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,33747.79,23623.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43711.4744,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,89768.8,62838.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71815.04,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,65676.03,45973.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,52540.824,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,26493.14,18545.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35982.7848,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,50028.86,35020.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59596.424,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,54052.44,37836.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43241.952,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,42724.18,29906.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34179.344,,
Knee Procedures With Principal Diagnosis Of Infection With McC,485,MS-DRG,,,,,,,inpatient,,,78688.59,55082.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,65323.0304,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,38633.42,27043.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42973.8648,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,68635.57,48044.899,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,54908.456,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,35436.81,24805.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28349.448,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,77413.36,54189.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71957.464,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,79988.8,55992.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,63991.04,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,52007.74,36405.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,41606.192,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC,495,MS-DRG,,,,,,,inpatient,,,55215.82,38651.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71335.3592,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC,499,MS-DRG,,,,,,,inpatient,,,24343.66,17040.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,23522.4512,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,43692.12,30584.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,64206.484,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,30673.94,21471.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36169.2136,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,41306.96,28914.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,53628.676,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,37180.29,26026.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35575.4784,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,63266.34,44286.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50613.072,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,57782.59,40447.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,57914.512,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,39749.27,27824.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39745.8096,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,26213.06,18349.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30507.452,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,64680.35,45276.245,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,62660.3408,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,33187.16,23231.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40763.0624,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,28664.41,20065.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30246.0464,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,52006.98,36404.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,72622.1232,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,60945.78,42662.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48756.624,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,27733.63,19413.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29040.3384,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,64155.47,44908.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59061.4544,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59467.45,41627.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47573.96,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,24348.24,17043.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26949.0936,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,14748.61,10324.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4918.661435,16432.0776,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,34525.72,24168.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40987.9928,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,27528.18,19269.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26229.7216,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,28046.03,19632.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37790.3336,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,29133.49,20393.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7548.68,23306.792,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,17251.52,12076.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5616.11,15313.5048,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,10607.77,7425.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3537.691295,51201.0488,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,22929.4,16050.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7646.9549,23459.6328,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,15898.64,11129.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5302.19644,15120.9968,,
Septic Arthritis Without Cc/McC,550,MS-DRG,,,,,,,inpatient,,,13751.03,9625.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4585.968505,17469.5944,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,34050.51,23835.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34576.4632,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,21070.26,14749.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6815.74,19530.4432,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,37105.01,25973.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29684.008,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,33214.93,23250.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5718.85,26571.944,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC,555,MS-DRG,,,,,,,inpatient,,,16910.44,11837.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5639.63174,27285.476,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,38978.42,27284.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5833.89,31182.736,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,25775.81,18043.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31403.1208,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,17322.32,12125.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5776.99372,17504.0432,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,46066.43,32246.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37612.0104,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,43659.99,30561.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34927.992,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,35419.71,24793.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5723.92,28335.768,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,23360.4,16352.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29660.4168,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,23376.03,16363.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6300.58,18700.824,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,24152.97,16907.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31798.2688,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,26103.05,18272.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7280.97,20882.44,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,12203.73,8542.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4069.943955,15157.472,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,58121.61,40685.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,61002.7456,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,22908.56,16035.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7640.00476,33938.1472,,
Skin Debridement Without Cc/McC,572,MS-DRG,,,,,,,inpatient,,,34042.21,23829.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,27233.768,,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,40320.12,28224.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,124781.6592,,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,31675.49,22172.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,70208.6808,,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC,575,MS-DRG,,,,,,,inpatient,,,33248.67,23274.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40457.076,,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,inpatient,,,22694.73,15886.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7568.692455,53954.9264,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,47774,33441.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,66042.4024,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,21385.31,14969.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7132.000885,35926.0456,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,107178.51,75024.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,85742.808,,
Breast Biopsy- Local Excision And Other Breast Procedures Without Cc/McC,585,MS-DRG,,,,,,,inpatient,,,37278.64,26095.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40224.04,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,53897.07,37727.949,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43117.656,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,22540.18,15778.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5923.61,18032.144,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,26958.01,18870.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7157.25,21905.384,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,36927.76,25849.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35593.716,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,9105.56,6373.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3036.70426,21862.8296,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,5148.62,3604.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1717.06477,12148.268,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,21201.17,14840.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7070.590195,29775.9216,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,14711.96,10298.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4906.43866,17850.5576,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,29329.16,20530.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30106.2248,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21984.9,15389.43,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6578.42,18717.8568,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,26207.89,18345.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32627.0664,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,18364.58,12855.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5973.54,17514.1752,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,63303.79,44312.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,78318.3336,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,33293.26,23305.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39154.1008,,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,inpatient,,,47713.27,33399.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38170.616,,
O.R. Procedures For Obesity Without Cc/McC,621,MS-DRG,,,,,,,inpatient,,,43994.97,30796.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35195.976,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,68839.88,48187.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,75868.416,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,19840.3,13888.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6616.74005,38785.296,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,624,MS-DRG,,,,,,,inpatient,,,15962.42,11173.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5323.46707,20326.8184,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,76735.34,53714.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,79967.8232,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,36824.85,25777.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45596.0264,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,27285.79,19100.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29510.4632,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,17323.96,12126.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5777.54066,18586.1408,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,11395.93,7977.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3800.542655,12697.4224,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,21542.6,15079.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7184.4571,26912.6184,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,14225.97,9958.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4744.360995,15836.316,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,13622.93,9536.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4543.247155,25149.6504,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,60349.49,42244.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48279.592,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,13236.15,9265.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4414.256025,20942.844,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13028.88,9120.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4345.13148,15785.656,,
Major Bladder Procedures Without Cc/McC,655,MS-DRG,,,,,,,inpatient,,,55359.22,38751.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44287.376,,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,47307.79,33115.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,66014.0328,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,42988.03,30091.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37042.592,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,30491.37,21343.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,52366.2288,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,26889.16,18822.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,27151.7336,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,19523.55,13666.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6511.103925,20803.0224,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,57156.94,40009.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,63211.5216,,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,29787.18,20851.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30949.2072,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,15013.42,10509.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5006.97557,21881.0672,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,28865.76,20206.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,69574.4176,,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,28047.28,19633.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33378.8608,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,51984.11,36388.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59091.8504,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,30494.67,21346.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31358.54,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,12447.8,8713.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4151.3413,19364.2784,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,72572.36,50800.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,84906.16,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,49815.27,34870.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46775.3912,,
Other Kidney And Urinary Tract Procedures Without Cc/McC,675,MS-DRG,,,,,,,inpatient,,,67065.03,46945.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,53652.024,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25198.22,17638.754,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30436.528,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,16815.75,11771.025,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5608.052625,18012.6696,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,11199.54,7839.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3735.04659,12310.38,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,17030.3,11921.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5679.60505,38209.7984,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,10555.37,7388.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3520.215895,21329.8864,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,21612.22,15128.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7207.67537,23716.9856,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,14540.91,10178.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4849.393485,16263.8864,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,27273.94,19091.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29794.1592,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,11406.89,7984.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3804.197815,15834.2896,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,22314.56,15620.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7441.90576,22851.7128,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,14767.92,10337.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4925.10132,14016.6088,,
Urethral Stricture,697,MS-DRG,,,,,,,inpatient,,,14675.76,10273.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4894.36596,20300.4752,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,24798.67,17359.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34061.7576,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,17120.52,11984.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5709.69342,20665.2272,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,41107.29,28775.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5388.92,32885.832,,
Major Male Pelvic Procedures With Cc/McC,707,MS-DRG,,,,,,,inpatient,,,35017.36,24512.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39322.292,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,31613.04,22129.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30039.3536,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,20964.14,14674.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6991.54069,45533.208,,
Penis Procedures Without Cc/McC,710,MS-DRG,,,,,,,inpatient,,,68393.44,47875.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,54714.752,,
Testes Procedures With Cc/McC,711,MS-DRG,,,,,,,inpatient,,,36907.35,25835.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38716.3984,,
Testes Procedures Without Cc/McC,712,MS-DRG,,,,,,,inpatient,,,18463.04,12924.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6157.42384,21674.3744,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,14941.94,10459.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4983.13699,29299.7176,,
Transurethral Prostatectomy Without Cc/McC,714,MS-DRG,,,,,,,inpatient,,,10164.77,7115.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3389.950795,19040.0544,,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC,715,MS-DRG,,,,,,,inpatient,,,36701.12,25690.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45760.1648,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,23580.89,16506.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37597.8256,,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC,718,MS-DRG,,,,,,,inpatient,,,27747.61,19423.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,24961.1952,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,48176.72,33723.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38541.376,,
Benign Prostatic Hypertrophy With McC,725,MS-DRG,,,,,,,inpatient,,,31783.16,22248.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25595.4584,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,10731.22,7511.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3578.86187,15082.4952,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,9268.85,6488.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3091.161475,16557.7144,,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC,739,MS-DRG,,,,,,,inpatient,,,70791.15,49553.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,80664.9048,,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,inpatient,,,61565.64,43095.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,49252.512,,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC,741,MS-DRG,,,,,,,inpatient,,,66917.01,46841.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,53533.608,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,24878.38,17414.866,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37014.2224,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,27909.66,19536.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,24288.4304,,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,16030.6,11221.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5346.2051,19354.1464,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,22664.36,15865.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7558.56406,22495.0664,,
Infections- Female Reproductive System With McC,757,MS-DRG,,,,,,,inpatient,,,15549.35,10884.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5185.708225,28677.6128,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,10151.59,7106.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3385.555265,20655.0952,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,10881.96,7617.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3629.13366,19970.172,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14849.95,10394.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4952.458325,13906.65298,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,25190.93,17633.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28156.828,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,6415.51,4490.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2139.572585,21802.0376,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,10227.7,7159.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3410.93795,14456.3376,,
Abortion Without D&C,779,MS-DRG,,,,,,,inpatient,,,13854.84,9698.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4620.58914,18940.7608,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,19969.28,13978.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6659.75488,23129.64586,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,17660.24,12362.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5889.69004,14128.192,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,16297.53,11408.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5435.226255,13038.024,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,19789.47,13852.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6599.788245,20332.32622,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,17268.46,12087.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5759.03141,13814.768,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,16414.17,11489.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5474.125695,13131.336,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,4752.37,3326.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1584.915395,22641.16608,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,54759.69,38331.783,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2909,73865.99995,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39693.75,27785.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2909,50556.23959,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,7967.7,5577.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2657.22795,30643.57784,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,10068.5,7047.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2909,51923.98297,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5320.51,3724.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1774.390085,18604.71546,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4248.78,2974.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1378.34,7947.23,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,9202.02,6441.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3068.87367,12322.49451,,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,inpatient,,,55562.6,38893.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59041.1904,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,36233.96,25363.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28987.168,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,14129.33,9890.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4712.131555,12691.01849,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13166.38,9216.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4390.98773,10533.104,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,12520.32,8764.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4175.52672,10016.256,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,50163.84,35114.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46412.6656,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,18648.29,13053.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6219.204715,25096.964,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,10877.8,7614.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3627.7463,19285.2488,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,32327.52,22629.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28507.3952,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,22300.24,15610.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6364.97,18701.6456,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,33797.91,23658.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31366.6456,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,19042.28,13329.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6350.60038,42357.8392,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,19035.73,13325.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6348.415955,20590.2504,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,34218.62,23953.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,51371.2664,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,53653,37557.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45233.3008,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,70337.4,49236.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,94819.3088,,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,inpatient,,,93776.03,65643.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,75020.824,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,73575.27,51502.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,96764.6528,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,inpatient,,,54189.56,37932.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47816.9608,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,45890.81,32123.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36712.648,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,19580.15,13706.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6529.980025,62486.0704,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC,830,MS-DRG,,,,,,,inpatient,,,39587.15,27711.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31669.72,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,19450.76,13615.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6486.82846,23321.8376,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,17150.01,12005.007,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5642.16,15143.2872,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,11361.65,7953.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3789.110275,10533.2272,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,9828.38,6879.866,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3277.76473,111997.1016,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,18619.01,13033.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6209.439835,43279.8512,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,24808.35,17365.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,64630.0016,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,16962.7,11873.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5657.06045,31771.9256,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,31741.3,22218.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25393.04,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,19222.18,13455.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6410.59703,38361.7784,,
Radiotherapy,849,MS-DRG,,,,,,,inpatient,,,58144.26,40700.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,54123.1176,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,85769.92,60038.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,101350.396,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,33994.9,23796.43,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40491.5248,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65980.01,46186.007,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,91416.9832,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,32658.71,22861.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44153.2296,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,20565.93,14396.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6858.737655,37257.3904,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,17400.21,12180.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5802.970035,20261.9736,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,17612.23,12328.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5873.678705,18195.0456,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,43267.27,30287.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34613.816,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,18403.74,12882.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6057.47,17927.5608,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,61414.22,42989.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,49131.376,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,15482.04,10837.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5163.26034,21277.2,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,13610,9527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4538.935,14579.948,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,148503.39,103952.373,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,140966.516,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,33194.92,23236.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39764.0472,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,18792.68,13154.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6267.35878,20892.184,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,12279.31,8595.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4095.149885,19425.0704,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,25117.86,17582.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33842.9064,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,22405.38,15683.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7472.19423,28562.108,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,13917.07,9741.949,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3961.38,12646.7624,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,48007.28,33605.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38405.824,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,20565.28,14395.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5972.81,17876.9008,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,61408.52,42985.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,80721.644,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,26863.69,18804.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40872.488,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,27835,19484.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25698.8048,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,30162.14,21113.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32791.2048,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42212,29548.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35214.7792,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,17347.78,12143.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4755.82,13878.224,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,43962.28,30773.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35169.824,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,17818.34,12472.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5723.92,17921.4816,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,31482.85,22037.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36949.3776,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,15673.65,10971.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5227.162275,20584.1712,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,7247.46,5073.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2417.02791,13933.5264,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,28001.68,19601.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6731.81,22401.344,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC,939,MS-DRG,,,,,,,inpatient,,,23950.54,16765.378,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,64313.8832,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,49540.17,34678.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42783.3832,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC,941,MS-DRG,,,,,,,inpatient,,,17064.75,11945.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5691.094125,39599.9088,,
Rehabilitation With Cc/McC,945,MS-DRG,,,,,,,inpatient,,,45131.85,31592.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36105.48,,
Rehabilitation Without Cc/McC,946,MS-DRG,,,,,,,inpatient,,,44615.43,31230.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35692.344,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,22069.35,15448.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7360.128225,26061.5304,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,17906.41,12534.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5684.12,16099.748,,
Aftercare With Cc/McC,949,MS-DRG,,,,,,,inpatient,,,33492.73,23444.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26794.184,,
Aftercare Without Cc/McC,950,MS-DRG,,,,,,,inpatient,,,9898.64,6929.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3301.19644,11876.7304,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,4337.06,3035.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1446.40951,11487.6616,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,61892.75,43324.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,77453.0608,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,12905.91,9034.137,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4304.120985,30400.0528,,
Other Multiple Significant Trauma Without Cc/McC,965,MS-DRG,,,,,,,inpatient,,,19234.18,13463.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6414.59903,18490.9,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,37958.81,26571.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,60508.304,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,12545.67,8781.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4183.980945,29216.6352,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,108861.48,76203.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,96341.1352,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,62893.24,44025.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50314.592,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,59507.83,41655.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47606.264,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51559.92,36091.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,70984.792,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,16279.53,11395.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5429.223255,34773.024,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,989,MS-DRG,,,,,,,inpatient,,,64497.43,45148.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,51597.944,,
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,inpatient,,,7296.22,5107.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2433.28937,7947.23,,
LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT,1-Jan,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133764.1397,,,133764.1397,103405.0931,149414.3361,case rate,
LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT,2-Jan,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,146420.7796,,,146420.7796,119539.9493,155243.7215,case rate,
LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT,3-Jan,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,182462.9492,,,182462.9492,142112.4189,182462.9492,case rate,
LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT,4-Jan,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,356163.0583,,,356163.0583,226313.5322,358242.4353,case rate,
HEART &/OR LUNG TRANSPLANT,1-Feb,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,181680.7104,,,181680.7104,142837.3308,196067.4461,case rate,
HEART &/OR LUNG TRANSPLANT,2-Feb,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,202322.9873,,,202322.9873,166618.3992,253130.9776,case rate,
HEART &/OR LUNG TRANSPLANT,3-Feb,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,260985.9824,,,260985.9824,234168.8061,315100.0259,case rate,
HEART &/OR LUNG TRANSPLANT,4-Feb,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,425881.9225,,,425881.9225,425881.9225,555938.1417,case rate,
BONE MARROW TRANSPLANT,1-Mar,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,92529.88267,,,92529.88267,92529.88267,92529.88267,case rate,
BONE MARROW TRANSPLANT,2-Mar,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128648.651,,,128648.651,128648.651,128648.651,case rate,
BONE MARROW TRANSPLANT,3-Mar,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,211522.2079,,,211522.2079,211522.2079,211522.2079,case rate,
BONE MARROW TRANSPLANT,4-Mar,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,401490.6372,,,401490.6372,401490.6372,401490.6372,case rate,
TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO,1-Apr,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,132148.001,,,132148.001,79313.52487,138057.5126,case rate,
TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO,2-Apr,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,146832.9447,,,146832.9447,114964.0976,168236.4684,case rate,
TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO,3-Apr,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,201018.099,,,201018.099,152444.2688,229698.5157,case rate,
TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO,4-Apr,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,303583.269,,,303583.269,229192.1499,327380.718,case rate,
TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,1-May,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,97435.7779,,,97435.7779,74467.9961,103545.3878,case rate,
TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,2-May,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,108263.6562,,,108263.6562,82840.35727,126757.0225,case rate,
TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,3-May,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,140374.1479,,,140374.1479,100813.4712,159926.1579,case rate,
TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,4-May,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,210366.6853,,,210366.6853,147899.3435,217638.6507,case rate,
PANCREAS TRANSPLANT,1-Jun,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,127154.4325,,,127154.4325,98346.79155,172141.5032,case rate,
PANCREAS TRANSPLANT,2-Jun,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,166559.7875,,,166559.7875,122912.1503,174392.5878,case rate,
PANCREAS TRANSPLANT,3-Jun,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,171673.7113,,,171673.7113,142933.8207,192809.1193,case rate,
PANCREAS TRANSPLANT,4-Jun,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,266151.9885,,,266151.9885,214875.7587,298355.4712,case rate,
"EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES",110-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11983.24044,,,11983.24044,7804.554759,17174.7516,case rate,
"EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES",110-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16137.63269,,,16137.63269,10054.75053,19969.08136,case rate,
"EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES",110-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24032.64717,,,24032.64717,18364.0221,36768.202,case rate,
"EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES",110-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51808.26389,,,51808.26389,29642.21606,75209.4764,case rate,
VERTIGO & OTHER LABYRINTH DISORDERS,111-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9912.323894,,,9912.323894,4173.810074,13335.366,case rate,
VERTIGO & OTHER LABYRINTH DISORDERS,111-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11053.94315,,,11053.94315,5069.434998,15320.0484,case rate,
VERTIGO & OTHER LABYRINTH DISORDERS,111-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14226.4341,,,14226.4341,7409.93549,18497.04,case rate,
VERTIGO & OTHER LABYRINTH DISORDERS,111-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26795.70161,,,26795.70161,16098.398,32429.8104,case rate,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5418.112181,,,5418.112181,3541.677013,8046.0892,case rate,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8064.36246,,,8064.36246,5316.845198,11833.1064,case rate,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13989.95683,,,13989.95683,9272.934296,17242.2408,case rate,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31672.92746,,,31672.92746,20706.99669,43255.2448,case rate,
DENTAL & ORAL DISEASES & INJURIES,114-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8316.72927,,,8316.72927,4800.994931,9924.4084,case rate,
DENTAL & ORAL DISEASES & INJURIES,114-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12258.43843,,,12258.43843,5801.76919,13095.4044,case rate,
DENTAL & ORAL DISEASES & INJURIES,114-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20430.87785,,,20430.87785,12922.23475,24874.2536,case rate,
DENTAL & ORAL DISEASES & INJURIES,114-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46078.94144,,,46078.94144,22504.43179,51689.32038,case rate,
"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",115-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8763.080871,,,8763.080871,5154.791517,11040.7332,case rate,
"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",115-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12607.98823,,,12607.98823,7210.770279,15257.5584,case rate,
"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",115-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18056.39486,,,18056.39486,11860.84499,23439.22188,case rate,
"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",115-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40837.39976,,,40837.39976,23846.63213,54355.1576,case rate,
MAJOR RESPIRATORY & CHEST PROCEDURES,120-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33493.64395,,,33493.64395,16750.90759,44865.3204,case rate,
MAJOR RESPIRATORY & CHEST PROCEDURES,120-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41466.07981,,,41466.07981,22197.64314,55086.1848,case rate,
MAJOR RESPIRATORY & CHEST PROCEDURES,120-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,63315.25953,,,63315.25953,35911.59053,74813.028,case rate,
MAJOR RESPIRATORY & CHEST PROCEDURES,120-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,119694.5145,,,119694.5145,76282.74992,130499.1168,case rate,
OTHER RESPIRATORY & CHEST PROCEDURES,121-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22882.50133,,,22882.50133,12586.99393,32674.7712,case rate,
OTHER RESPIRATORY & CHEST PROCEDURES,121-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29728.46516,,,29728.46516,16524.52726,42243.24,case rate,
OTHER RESPIRATORY & CHEST PROCEDURES,121-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50804.15335,,,50804.15335,32257.34188,64252.218,case rate,
OTHER RESPIRATORY & CHEST PROCEDURES,121-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,111072.2727,,,111072.2727,50793.31406,125575.7972,case rate,
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,130-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59760.3162,,,59760.3162,44137.97968,78087.504,case rate,
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,130-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66401.02008,,,66401.02008,44144.16494,78105.0012,case rate,
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,130-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73780.68785,,,73780.68785,50414.77645,95607.2004,case rate,
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,130-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,105318.0928,,,105318.0928,64377.37109,125901.2896,case rate,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25363.77727,,,25363.77727,18351.65159,28610.16,case rate,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30660.06965,,,30660.06965,30617.01225,37344.57067,case rate,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40575.76405,,,40575.76405,33589.6458,52937.0888,case rate,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,57086.01847,,,57086.01847,47173.70283,71140.134,case rate,
BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8412.10663,,,8412.10663,6492.043648,12236.0264,case rate,
BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11399.84156,,,11399.84156,9144.280992,16260.1076,case rate,
BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18082.29561,,,18082.29561,18082.29561,27318.5564,case rate,
BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36102.79858,,,36102.79858,27233.67777,49773.3856,case rate,
PULMONARY EDEMA & RESPIRATORY FAILURE,133-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10705.87798,,,10705.87798,6645.437972,19104.538,case rate,
PULMONARY EDEMA & RESPIRATORY FAILURE,133-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13948.58785,,,13948.58785,7074.694669,19143.9288,case rate,
PULMONARY EDEMA & RESPIRATORY FAILURE,133-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21337.36402,,,21337.36402,12283.91643,28336.4976,case rate,
PULMONARY EDEMA & RESPIRATORY FAILURE,133-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36411.80196,,,36411.80196,20103.3158,44045.4516,case rate,
PULMONARY EMBOLISM,134-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13023.10244,,,13023.10244,4556.058833,14609.8404,case rate,
PULMONARY EMBOLISM,134-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16925.34857,,,16925.34857,6642.96387,19386.4932,case rate,
PULMONARY EMBOLISM,134-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24680.86814,,,24680.86814,10252.67869,31292.8808,case rate,
PULMONARY EMBOLISM,134-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43757.78471,,,43757.78471,17673.74764,52999.2848,case rate,
MAJOR CHEST & RESPIRATORY TRAUMA,135-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13136.51604,,,13136.51604,6071.446308,16967.2848,case rate,
MAJOR CHEST & RESPIRATORY TRAUMA,135-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16566.85088,,,16566.85088,7148.917729,19744.3404,case rate,
MAJOR CHEST & RESPIRATORY TRAUMA,135-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24477.35364,,,24477.35364,10658.43142,28322.9676,case rate,
MAJOR CHEST & RESPIRATORY TRAUMA,135-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45321.31938,,,45321.31938,19730.96345,47714.8644,case rate,
RESPIRATORY MALIGNANCY,136-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11995.4786,,,11995.4786,6234.73704,16070.80662,case rate,
RESPIRATORY MALIGNANCY,136-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15684.19901,,,15684.19901,8144.743784,20394.2364,case rate,
RESPIRATORY MALIGNANCY,136-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25303.89056,,,25303.89056,12849.24874,32335.7004,case rate,
RESPIRATORY MALIGNANCY,136-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41580.2959,,,41580.2959,20995.22957,47550.9152,case rate,
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,137-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13163.46004,,,13163.46004,5451.683757,15065.0892,case rate,
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,137-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15996.31209,,,15996.31209,7466.839836,21370.5456,case rate,
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,137-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24869.97774,,,24869.97774,9037.894606,34763.4176,case rate,
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,137-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43009.15068,,,43009.15068,15549.73107,54154.0572,case rate,
BRONCHIOLITIS & RSV PNEUMONIA,138-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5479.844645,,,5479.844645,3455.083443,10110.9964,case rate,
BRONCHIOLITIS & RSV PNEUMONIA,138-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7681.629203,,,7681.629203,5805.480343,13067.3796,case rate,
BRONCHIOLITIS & RSV PNEUMONIA,138-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16451.21034,,,16451.21034,7324.578971,28295.0336,case rate,
BRONCHIOLITIS & RSV PNEUMONIA,138-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40297.37611,,,40297.37611,13445.50732,62687.3484,case rate,
OTHER PNEUMONIA,139-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7853.605377,,,7853.605377,4274.011205,11010.738,case rate,
OTHER PNEUMONIA,139-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11315.33811,,,11315.33811,5524.669766,15272.556,case rate,
OTHER PNEUMONIA,139-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18846.77906,,,18846.77906,8252.367221,23595.0892,case rate,
OTHER PNEUMONIA,139-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37611.5023,,,37611.5023,13963.83169,44984.2936,case rate,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9536.411904,,,9536.411904,4930.885286,13080.4068,case rate,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12064.27308,,,12064.27308,6179.069745,16109.922,case rate,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17107.83752,,,17107.83752,7526.218284,20987.0036,case rate,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35693.84357,,,35693.84357,12126.81095,40850.3328,case rate,
ASTHMA,141-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6921.59964,,,6921.59964,4437.301937,9818.6752,case rate,
ASTHMA,141-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10231.77987,,,10231.77987,5702.80511,13912.7736,case rate,
ASTHMA,141-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15603.58769,,,15603.58769,7042.531343,19440.3964,case rate,
ASTHMA,141-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28336.68598,,,28336.68598,11905.37882,34247.1908,case rate,
INTERSTITIAL & ALVEOLAR LUNG DISEASES,142-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12477.30079,,,12477.30079,6514.310566,15147.576,case rate,
INTERSTITIAL & ALVEOLAR LUNG DISEASES,142-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14974.84745,,,14974.84745,8622.24547,17837.1456,case rate,
INTERSTITIAL & ALVEOLAR LUNG DISEASES,142-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21937.97656,,,21937.97656,11563.95275,27590.1456,case rate,
INTERSTITIAL & ALVEOLAR LUNG DISEASES,142-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43126.57678,,,43126.57678,17954.55821,57668.1312,case rate,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES",143-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8723.577711,,,8723.577711,5546.936684,12253.0392,case rate,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES",143-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13473.28599,,,13473.28599,7136.547219,17362.2216,case rate,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES",143-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21890.52864,,,21890.52864,11880.6378,26595.0096,case rate,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES",143-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38264.05678,,,38264.05678,18578.03192,42660.2364,case rate,
"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",144-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8588.155502,,,8588.155502,5226.540475,11890.5972,case rate,
"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",144-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10771.40226,,,10771.40226,6706.053471,15649.9956,case rate,
"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",144-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15710.32045,,,15710.32045,10366.48738,22108.962,case rate,
"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",144-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29959.76629,,,29959.76629,14954.70954,38556.33,case rate,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56987.81229,,,56987.81229,32815.25188,74752.23481,case rate,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,64958.44252,,,64958.44252,47755.1168,87402.47434,case rate,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91863.36465,,,91863.36465,80727.47416,132108.8592,case rate,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,208329.5943,,,208329.5943,206156.9348,247472.8459,case rate,
CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT,161-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79731.80178,,,79731.80178,79731.80178,339865.6128,case rate,
CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT,161-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,105224.0396,,,105224.0396,105224.0396,357755.25,case rate,
CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT,161-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,172491.9223,,,172491.9223,172491.9223,445571.1972,case rate,
CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT,161-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,424790.8809,,,424790.8809,352820.5528,581606.928,case rate,
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION,162-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82152.32832,,,82152.32832,40249.92839,107445.306,case rate,
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION,162-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95116.88824,,,95116.88824,46683.83064,125907.3516,case rate,
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION,162-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129195.1148,,,129195.1148,60055.1149,158864.5776,case rate,
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION,162-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,205671.3466,,,205671.3466,91535.58875,231947.8824,case rate,
CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION,163-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72797.7433,,,72797.7433,36385.38106,93974.9616,case rate,
CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION,163-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79988.98361,,,79988.98361,36882.67557,103988.3592,case rate,
CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION,163-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,106225.6623,,,106225.6623,50725.27626,131396.4732,case rate,
CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION,163-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,191399.1097,,,191399.1097,83557.84685,197373.4152,case rate,
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,165-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,67721.03552,,,67721.03552,44446.00538,91047.93,case rate,
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,165-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78082.01821,,,78082.01821,45162.25791,110872.2576,case rate,
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,165-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,98883.47141,,,98883.47141,45972.52631,133306.1676,case rate,
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,165-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,159236.9569,,,159236.9569,66108.00544,180493.6164,case rate,
CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,166-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,53046.80532,,,53046.80532,24844.93228,83816.5872,case rate,
CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,166-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,61224.42087,,,61224.42087,29920.55254,93327.5652,case rate,
CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,166-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80640.27415,,,80640.27415,37668.20295,110829.7644,case rate,
CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,166-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,140876.8351,,,140876.8351,61902.03204,162698.964,case rate,
OTHER CARDIOTHORACIC PROCEDURES,167-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54643.90463,,,54643.90463,32102.7105,70466.2236,case rate,
OTHER CARDIOTHORACIC PROCEDURES,167-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,63653.23324,,,63653.23324,33589.6458,73245.7788,case rate,
OTHER CARDIOTHORACIC PROCEDURES,167-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,84324.05918,,,84324.05918,53570.49356,110579.8044,case rate,
OTHER CARDIOTHORACIC PROCEDURES,167-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,158187.7257,,,158187.7257,99594.97601,177539.0892,case rate,
MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES,169-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32646.08148,,,32646.08148,25621.80031,70681.1892,case rate,
MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES,169-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44466.91559,,,44466.91559,33672.52822,71633.5368,case rate,
MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES,169-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74364.26729,,,74364.26729,40465.17526,93605.0208,case rate,
MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES,169-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,143843.2235,,,143843.2235,68057.59782,152280.6312,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",170-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43824.09144,,,43824.09144,34434.55164,56092.4992,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",170-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45671.19018,,,45671.19018,37556.86836,60215.364,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",170-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56578.83722,,,56578.83722,44554.86587,76367.7792,case rate,
"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",170-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95002.55177,,,95002.55177,59987.07709,107377.8168,case rate,
"PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK",171-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30166.53093,,,30166.53093,15793.43012,39288.7128,case rate,
"PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK",171-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35250.80229,,,35250.80229,17834.56427,45050.2908,case rate,
"PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK",171-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46552.61823,,,46552.61823,22882.9694,61945.1428,case rate,
"PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK",171-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,87035.09143,,,87035.09143,39432.23768,123641.5016,case rate,
OTHER VASCULAR PROCEDURES,173-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34336.37134,,,34336.37134,34336.37134,34336.37134,case rate,
OTHER VASCULAR PROCEDURES,173-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41618.29437,,,41618.29437,41618.29437,41618.29437,case rate,
OTHER VASCULAR PROCEDURES,173-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59056.46177,,,59056.46177,59056.46177,59056.46177,case rate,
OTHER VASCULAR PROCEDURES,173-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,115277.042,,,115277.042,115277.042,115277.042,case rate,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI,174-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37727.04252,,,37727.04252,13742.39956,48872.1792,case rate,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI,174-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40824.3591,,,40824.3591,16797.91553,53031.5136,case rate,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI,174-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52773.23239,,,52773.23239,22014.5596,65057.0892,case rate,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI,174-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,87926.43038,,,87926.43038,33365.73957,90917.9508,case rate,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI,175-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34692.98316,,,34692.98316,18256.39866,49214.6244,case rate,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI,175-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39419.27845,,,39419.27845,22254.54749,55626.0984,case rate,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI,175-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50881.75529,,,50881.75529,29002.6607,68651.514,case rate,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI,175-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,88783.26174,,,88783.26174,51064.22823,101808.6324,case rate,
CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,176-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26979.51469,,,26979.51469,10411.02122,40633.4976,case rate,
CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,176-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52041.85215,,,52041.85215,17778.89697,54740.7728,case rate,
CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,176-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,57509.29814,,,57509.29814,31694.48367,74680.5492,case rate,
CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,176-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,102401.4194,,,102401.4194,71004.2533,123690.2064,case rate,
CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22642.83412,,,22642.83412,10907.07867,29112.8412,case rate,
CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29048.06386,,,29048.06386,15745.18513,42025.7748,case rate,
CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45631.28577,,,45631.28577,21154.80915,56468.4636,case rate,
CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,93471.09712,,,93471.09712,29189.4554,131328.9272,case rate,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21970.43777,,,21970.43777,12224.53798,28537.9332,case rate,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29824.68515,,,29824.68515,14166.70805,35626.7988,case rate,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46583.45437,,,46583.45437,23586.85142,50161.074,case rate,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91790.59779,,,91790.59779,48915.47064,99909.5812,case rate,
ACUTE MYOCARDIAL INFARCTION,190-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13490.41941,,,13490.41941,4908.618368,18979.4628,case rate,
ACUTE MYOCARDIAL INFARCTION,190-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16059.10787,,,16059.10787,6489.569546,20691.6888,case rate,
ACUTE MYOCARDIAL INFARCTION,190-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22754.70289,,,22754.70289,9506.736935,30077.9856,case rate,
ACUTE MYOCARDIAL INFARCTION,190-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46216.06897,,,46216.06897,15969.09136,58323.2624,case rate,
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE,191-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19667.05646,,,19667.05646,6754.29846,22648.8756,case rate,
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE,191-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23431.75375,,,23431.75375,8429.265514,26550.7512,case rate,
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE,191-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30840.31159,,,30840.31159,11964.75727,34479.4824,case rate,
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE,191-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,70774.2145,,,70774.2145,23082.13461,70774.2145,case rate,
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE,192-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16744.02325,,,16744.02325,7564.566865,24296.112,case rate,
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE,192-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19347.07886,,,19347.07886,11895.48242,30232.662,case rate,
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE,192-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26635.48209,,,26635.48209,20402.68214,42398.2152,case rate,
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE,192-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,53728.81163,,,53728.81163,34344.24691,85359.8636,case rate,
ACUTE & SUBACUTE ENDOCARDITIS,193-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17413.39015,,,17413.39015,7518.795978,21391.2776,case rate,
ACUTE & SUBACUTE ENDOCARDITIS,193-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21827.4921,,,21827.4921,11648.07222,28570.7692,case rate,
ACUTE & SUBACUTE ENDOCARDITIS,193-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35752.8074,,,35752.8074,15821.88229,44640.1424,case rate,
ACUTE & SUBACUTE ENDOCARDITIS,193-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62225.62234,,,62225.62234,19017.18502,92551.7944,case rate,
HEART FAILURE,194-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9765.867283,,,9765.867283,5170.87318,12637.9776,case rate,
HEART FAILURE,194-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12292.28395,,,12292.28395,7424.780102,16587.3456,case rate,
HEART FAILURE,194-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19241.36929,,,19241.36929,10382.56904,26820.9884,case rate,
HEART FAILURE,194-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40318.46185,,,40318.46185,16741.01118,59882.3088,case rate,
CARDIAC ARREST,196-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7495.769744,,,7495.769744,5052.116284,12142.7324,case rate,
CARDIAC ARREST,196-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9873.482798,,,9873.482798,6543.99979,13425.3516,case rate,
CARDIAC ARREST,196-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15218.2463,,,15218.2463,9109.643564,20909.154,case rate,
CARDIAC ARREST,196-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35343.19033,,,35343.19033,18825.44212,43346.4656,case rate,
PERIPHERAL & OTHER VASCULAR DISORDERS,197-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9402.093135,,,9402.093135,5903.207372,12148.952,case rate,
PERIPHERAL & OTHER VASCULAR DISORDERS,197-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12953.04402,,,12953.04402,6915.11509,16425.9636,case rate,
PERIPHERAL & OTHER VASCULAR DISORDERS,197-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19607.51081,,,19607.51081,9851.874164,24482.4188,case rate,
PERIPHERAL & OTHER VASCULAR DISORDERS,197-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46150.82555,,,46150.82555,22813.69454,59374.3748,case rate,
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,198-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8357.095119,,,8357.095119,4095.875861,11513.1576,case rate,
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,198-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9809.142202,,,9809.142202,4888.825552,13757.7984,case rate,
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,198-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13942.72959,,,13942.72959,6854.499591,18152.0952,case rate,
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,198-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33022.9966,,,33022.9966,17462.21192,50185.9524,case rate,
HYPERTENSION,199-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8973.25614,,,8973.25614,4050.104974,12285.534,case rate,
HYPERTENSION,199-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10629.07854,,,10629.07854,5675.589988,15012.5976,case rate,
HYPERTENSION,199-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15425.89369,,,15425.89369,10229.17472,20679.1908,case rate,
HYPERTENSION,199-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35452.73185,,,35452.73185,16997.08074,50924.0116,case rate,
CARDIAC STRUCTURAL & VALVULAR DISORDERS,200-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10476.80379,,,10476.80379,4220.818012,12210.83862,case rate,
CARDIAC STRUCTURAL & VALVULAR DISORDERS,200-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12137.16032,,,12137.16032,6976.96764,15610.002,case rate,
CARDIAC STRUCTURAL & VALVULAR DISORDERS,200-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17982.72518,,,17982.72518,11180.46694,25948.1712,case rate,
CARDIAC STRUCTURAL & VALVULAR DISORDERS,200-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45696.99062,,,45696.99062,20948.22163,81673.714,case rate,
CRANIOTOMY FOR TRAUMA,20-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36238.9631,,,36238.9631,19805.18651,46704.93673,case rate,
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,201-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8299.194601,,,8299.194601,4022.889852,10910.754,case rate,
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,201-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10761.71205,,,10761.71205,5311.896994,14145.2364,case rate,
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,201-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16761.53786,,,16761.53786,9129.43638,22492.1468,case rate,
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,201-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39591.43518,,,39591.43518,15520.04185,52659.28,case rate,
CRANIOTOMY FOR TRAUMA,20-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50079.97556,,,50079.97556,23978.99658,58278.08069,case rate,
CRANIOTOMY FOR TRAUMA,20-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72299.22907,,,72299.22907,36220.85328,75333.59602,case rate,
CHEST PAIN,203-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8757.242669,,,8757.242669,3613.425971,11899.87798,case rate,
CHEST PAIN,203-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10316.10277,,,10316.10277,4734.194177,13795.2924,case rate,
CHEST PAIN,203-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13975.27104,,,13975.27104,7037.583139,17194.7484,case rate,
CHEST PAIN,203-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31244.27103,,,31244.27103,16674.21043,48828.0064,case rate,
CRANIOTOMY FOR TRAUMA,20-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,138336.3145,,,138336.3145,62844.6649,138336.3145,case rate,
SYNCOPE & COLLAPSE,204-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10025.95817,,,10025.95817,4154.017258,13440.3492,case rate,
SYNCOPE & COLLAPSE,204-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11534.68196,,,11534.68196,5446.735553,15799.9716,case rate,
SYNCOPE & COLLAPSE,204-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15011.04029,,,15011.04029,7779.813739,20356.7424,case rate,
SYNCOPE & COLLAPSE,204-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33717.34138,,,33717.34138,14922.54621,43966.3524,case rate,
CARDIOMYOPATHY,205-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8950.525271,,,8950.525271,5577.862959,12182.1232,case rate,
CARDIOMYOPATHY,205-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11805.22544,,,11805.22544,7204.585024,15472.2916,case rate,
CARDIOMYOPATHY,205-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18105.86911,,,18105.86911,9117.06587,30131.8888,case rate,
CARDIOMYOPATHY,205-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51079.15071,,,51079.15071,20627.82543,51189.07935,case rate,
"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",206-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10403.71592,,,10403.71592,8209.070436,16381.76726,case rate,
"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",206-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13037.5876,,,13037.5876,8331.538485,16672.44786,case rate,
"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",206-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21621.69047,,,21621.69047,13368.81016,25794.7544,case rate,
"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",206-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50071.08785,,,50071.08785,21965.07756,70582.094,case rate,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9729.152817,,,9729.152817,4987.789632,12897.936,case rate,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13037.30673,,,13037.30673,7229.326044,16159.914,case rate,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19028.98714,,,19028.98714,10315.76829,24938.5228,case rate,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39119.18283,,,39119.18283,19013.47387,52389.764,case rate,
CRANIOTOMY EXCEPT FOR TRAUMA,21-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39480.1081,,,39480.1081,20275.26589,42930.59558,case rate,
CRANIOTOMY EXCEPT FOR TRAUMA,21-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52692.52076,,,52692.52076,25641.59313,57433.07894,case rate,
CRANIOTOMY EXCEPT FOR TRAUMA,21-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80728.16818,,,80728.16818,40677.94803,86872.93991,case rate,
CRANIOTOMY EXCEPT FOR TRAUMA,21-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150116.9232,,,150116.9232,77535.88258,150116.9232,case rate,
"MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",220-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25027.36844,,,25027.36844,11795.28129,34484.4816,case rate,
"MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",220-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39501.87596,,,39501.87596,20573.39518,49487.0808,case rate,
"MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",220-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66731.39008,,,66731.39008,39021.53674,75362.94,case rate,
"MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",220-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133173.9998,,,133173.9998,106277.5255,146942.1964,case rate,
VENTRICULAR SHUNT PROCEDURES,22-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23772.93747,,,23772.93747,13846.31184,27305.94988,case rate,
MAJOR SMALL & LARGE BOWEL PROCEDURES,221-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25651.23348,,,25651.23348,25651.23348,30820.1912,case rate,
MAJOR SMALL & LARGE BOWEL PROCEDURES,221-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33855.57234,,,33855.57234,33855.57234,39032.1364,case rate,
MAJOR SMALL & LARGE BOWEL PROCEDURES,221-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56883.62747,,,56883.62747,56883.62747,64298.2248,case rate,
MAJOR SMALL & LARGE BOWEL PROCEDURES,221-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,120144.999,,,120144.999,120144.999,137003.2756,case rate,
VENTRICULAR SHUNT PROCEDURES,22-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34540.42753,,,34540.42753,18145.06407,34540.42753,case rate,
"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",222-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15798.23454,,,15798.23454,9287.778908,18402.0552,case rate,
"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",222-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23514.47164,,,23514.47164,15192.22333,31047.5316,case rate,
"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",222-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41695.3145,,,41695.3145,25201.20297,46377.5784,case rate,
"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",222-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100536.7258,,,100536.7258,58294.79132,114730.888,case rate,
VENTRICULAR SHUNT PROCEDURES,22-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72268.15218,,,72268.15218,29328.00511,72268.15218,case rate,
OTHER SMALL & LARGE BOWEL PROCEDURES,223-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20441.33043,,,20441.33043,10002.79439,25325.9472,case rate,
OTHER SMALL & LARGE BOWEL PROCEDURES,223-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27848.74471,,,27848.74471,15392.62559,38313.8688,case rate,
OTHER SMALL & LARGE BOWEL PROCEDURES,223-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48413.62033,,,48413.62033,20923.48061,55153.3396,case rate,
OTHER SMALL & LARGE BOWEL PROCEDURES,223-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,105247.5127,,,105247.5127,37913.13905,115653.462,case rate,
VENTRICULAR SHUNT PROCEDURES,22-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,144481.9148,,,144481.9148,65519.16916,144481.9148,case rate,
PERITONEAL ADHESIOLYSIS,224-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22133.66667,,,22133.66667,11619.62004,30657.594,case rate,
PERITONEAL ADHESIOLYSIS,224-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30581.92602,,,30581.92602,15476.74506,37911.4332,case rate,
PERITONEAL ADHESIOLYSIS,224-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47808.03227,,,47808.03227,20085.99709,55018.5816,case rate,
PERITONEAL ADHESIOLYSIS,224-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91264.63799,,,91264.63799,39683.35903,115448.2152,case rate,
APPENDECTOMY,225-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15077.02601,,,15077.02601,14927.04,15077.02601,case rate,
APPENDECTOMY,225-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20544.65256,,,20544.65256,20544.65256,22896.4208,case rate,
APPENDECTOMY,225-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36466.5326,,,36466.5326,36466.5326,42061.0816,case rate,
APPENDECTOMY,225-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74809.47533,,,74809.47533,74809.47533,84217.5304,case rate,
ANAL PROCEDURES,226-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12284.49968,,,12284.49968,8456.480636,20286.7536,case rate,
ANAL PROCEDURES,226-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17215.65366,,,17215.65366,12622.8684,26843.2044,case rate,
ANAL PROCEDURES,226-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29488.27632,,,29488.27632,16980.99908,39381.198,case rate,
ANAL PROCEDURES,226-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,60013.26482,,,60013.26482,40645.78471,80996.23441,case rate,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",227-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19097.54087,,,19097.54087,10607.71233,28880.3784,case rate,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",227-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24804.71426,,,24804.71426,14005.89142,36129.2184,case rate,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",227-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42883.09768,,,42883.09768,21309.44053,51061.8288,case rate,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",227-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90406.26181,,,90406.26181,45345.34146,109334.3484,case rate,
"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",228-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14305.52067,,,14305.52067,7252.830013,21943.9884,case rate,
"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",228-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18916.47636,,,18916.47636,9181.392522,28295.472,case rate,
"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",228-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30302.07351,,,30302.07351,13930.43131,38531.334,case rate,
"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",228-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,70896.5158,,,70896.5158,31251.61941,92377.6456,case rate,
OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,229-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21059.91902,,,21059.91902,11359.83933,27510.5976,case rate,
OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,229-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28861.04077,,,28861.04077,16394.6369,37928.9304,case rate,
OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,229-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48100.66462,,,48100.66462,27792.82482,57270.8352,case rate,
OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,229-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,103640.4825,,,103640.4825,51088.96925,119971.9376,case rate,
SPINAL PROCEDURES,23-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28462.03679,,,28462.03679,18366.4962,32752.26783,case rate,
SPINAL PROCEDURES,23-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40147.91012,,,40147.91012,24527.01018,44471.87877,case rate,
SPINAL PROCEDURES,23-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81964.34223,,,81964.34223,41133.1828,81964.34223,case rate,
SPINAL PROCEDURES,23-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,141447.2536,,,141447.2536,55129.17782,141447.2536,case rate,
DIGESTIVE MALIGNANCY,240-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13399.59625,,,13399.59625,8009.905225,17452.2072,case rate,
DIGESTIVE MALIGNANCY,240-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15778.57324,,,15778.57324,9018.10179,20171.772,case rate,
DIGESTIVE MALIGNANCY,240-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24439.7163,,,24439.7163,13940.32772,32827.0488,case rate,
DIGESTIVE MALIGNANCY,240-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51030.88022,,,51030.88022,27582.52615,61654.8948,case rate,
EXTRACRANIAL VASCULAR PROCEDURES,24-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20879.97802,,,20879.97802,9246.956225,20879.97802,case rate,
PEPTIC ULCER & GASTRITIS,241-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10788.39524,,,10788.39524,5443.0244,14755.1388,case rate,
PEPTIC ULCER & GASTRITIS,241-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13575.54481,,,13575.54481,7158.814137,18367.0608,case rate,
PEPTIC ULCER & GASTRITIS,241-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20403.1514,,,20403.1514,11687.65785,26773.2156,case rate,
PEPTIC ULCER & GASTRITIS,241-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51201.41189,,,51201.41189,26657.212,64884.9404,case rate,
EXTRACRANIAL VASCULAR PROCEDURES,24-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29326.31136,,,29326.31136,11849.71153,29326.31136,case rate,
MAJOR ESOPHAGEAL DISORDERS,242-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10136.34232,,,10136.34232,4658.734066,13460.346,case rate,
MAJOR ESOPHAGEAL DISORDERS,242-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13426.781,,,13426.781,6976.96764,17412.2136,case rate,
MAJOR ESOPHAGEAL DISORDERS,242-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20127.03053,,,20127.03053,10997.38339,25879.7556,case rate,
MAJOR ESOPHAGEAL DISORDERS,242-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52692.70132,,,52692.70132,26074.56098,65413.6064,case rate,
EXTRACRANIAL VASCULAR PROCEDURES,24-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58659.38379,,,58659.38379,21997.24088,58659.38379,case rate,
OTHER ESOPHAGEAL DISORDERS,243-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9138.43111,,,9138.43111,5304.474688,12677.9712,case rate,
OTHER ESOPHAGEAL DISORDERS,243-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11861.40058,,,11861.40058,6915.11509,16302.3912,case rate,
OTHER ESOPHAGEAL DISORDERS,243-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17940.57376,,,17940.57376,11024.59851,23763.6972,case rate,
OTHER ESOPHAGEAL DISORDERS,243-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43395.43501,,,43395.43501,22461.13501,47656.6484,case rate,
EXTRACRANIAL VASCULAR PROCEDURES,24-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,122463.5476,,,122463.5476,47518.84006,122463.5476,case rate,
DIVERTICULITIS & DIVERTICULOSIS,244-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9754.913131,,,9754.913131,4678.526882,12745.4604,case rate,
DIVERTICULITIS & DIVERTICULOSIS,244-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12391.4732,,,12391.4732,6540.288637,16652.3352,case rate,
DIVERTICULITIS & DIVERTICULOSIS,244-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19424.60055,,,19424.60055,10845.22612,25178.4708,case rate,
DIVERTICULITIS & DIVERTICULOSIS,244-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45101.63447,,,45101.63447,19779.20844,63707.3628,case rate,
INFLAMMATORY BOWEL DISEASE,245-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11371.79412,,,11371.79412,6521.732872,13647.816,case rate,
INFLAMMATORY BOWEL DISEASE,245-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13693.89379,,,13693.89379,8877.077976,17404.7148,case rate,
INFLAMMATORY BOWEL DISEASE,245-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20953.50726,,,20953.50726,13804.25211,25253.6492,case rate,
INFLAMMATORY BOWEL DISEASE,245-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41845.48268,,,41845.48268,24630.92246,50686.58497,case rate,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12188.74114,,,12188.74114,4878.929144,14457.6864,case rate,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14813.24361,,,14813.24361,6376.997905,18297.072,case rate,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22282.37029,,,22282.37029,9554.981924,26800.2564,case rate,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50018.98541,,,50018.98541,21514.79099,59117.298,case rate,
INTESTINAL OBSTRUCTION,247-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9249.035945,,,9249.035945,4421.220274,11575.6476,case rate,
INTESTINAL OBSTRUCTION,247-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11732.6592,,,11732.6592,6002.171452,14997.6,case rate,
INTESTINAL OBSTRUCTION,247-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18964.68667,,,18964.68667,10741.31383,24967.5476,case rate,
INTESTINAL OBSTRUCTION,247-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45704.75483,,,45704.75483,21418.30101,52984.7724,case rate,
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,248-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9776.560622,,,9776.560622,5063.249743,12750.4596,case rate,
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,248-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14060.11557,,,14060.11557,7340.660634,17547.5648,case rate,
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,248-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22381.07803,,,22381.07803,11489.72969,27343.4348,case rate,
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,248-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48411.6542,,,48411.6542,19904.15059,67099.118,case rate,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING",249-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7411.326473,,,7411.326473,4322.256194,10815.7692,case rate,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING",249-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9603.119881,,,9603.119881,5654.560121,13520.3364,case rate,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING",249-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14297.49565,,,14297.49565,9362.001968,19554.3708,case rate,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING",249-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37183.70856,,,37183.70856,19865.80201,41934.6164,case rate,
ABDOMINAL PAIN,251-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9168.063495,,,9168.063495,5001.397193,11383.1784,case rate,
ABDOMINAL PAIN,251-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11331.64896,,,11331.64896,5901.970321,14700.1476,case rate,
ABDOMINAL PAIN,251-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15888.51601,,,15888.51601,8885.737333,19404.3948,case rate,
ABDOMINAL PAIN,251-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34293.35724,,,34293.35724,13706.52508,40143.3716,case rate,
"MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE",252-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10085.6242,,,10085.6242,7087.065179,13850.2836,case rate,
"MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE",252-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13478.48219,,,13478.48219,8288.2417,17144.7564,case rate,
"MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE",252-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22149.49602,,,22149.49602,13444.27027,25749.144,case rate,
"MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE",252-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50998.59958,,,50998.59958,33788.81101,58758.6344,case rate,
OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10144.80872,,,10144.80872,5614.974489,13917.7728,case rate,
OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13251.05313,,,13251.05313,7647.449282,17984.622,case rate,
OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20298.04371,,,20298.04371,11075.3176,27712.4644,case rate,
OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44880.84611,,,44880.84611,20257.94718,49049.8388,case rate,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9275.418198,,,9275.418198,5711.464467,11923.092,case rate,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12567.8832,,,12567.8832,7617.760058,16644.8364,case rate,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18925.12332,,,18925.12332,12753.99581,25139.6232,case rate,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44011.0744,,,44011.0744,23382.738,54071.1292,case rate,
"MAJOR PANCREAS, LIVER & SHUNT PROCEDURES",260-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32748.8218,,,32748.8218,18315.77711,42770.6556,case rate,
"MAJOR PANCREAS, LIVER & SHUNT PROCEDURES",260-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41179.9076,,,41179.9076,22749.36789,54218.8236,case rate,
"MAJOR PANCREAS, LIVER & SHUNT PROCEDURES",260-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66199.65227,,,66199.65227,33478.31121,74310.6084,case rate,
"MAJOR PANCREAS, LIVER & SHUNT PROCEDURES",260-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,152399.9811,,,152399.9811,68009.35283,153966.198,case rate,
OTHER NERVOUS SYSTEM & RELATED PROCEDURES,26-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25211.46239,,,25211.46239,14776.5742,29410.56758,case rate,
MAJOR BILIARY TRACT PROCEDURES,261-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24939.13334,,,24939.13334,17556.22779,35706.786,case rate,
MAJOR BILIARY TRACT PROCEDURES,261-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36159.75615,,,36159.75615,20447.21598,46730.022,case rate,
MAJOR BILIARY TRACT PROCEDURES,261-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,53765.82703,,,53765.82703,28839.36996,64744.6392,case rate,
MAJOR BILIARY TRACT PROCEDURES,261-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,108923.5737,,,108923.5737,56363.75471,127306.9192,case rate,
OTHER NERVOUS SYSTEM & RELATED PROCEDURES,26-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34042.51518,,,34042.51518,18644.83267,38218.86582,case rate,
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC,262-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21620.58703,,,21620.58703,21620.58703,27235.6284,case rate,
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC,262-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28710.69202,,,28710.69202,28710.69202,33285.226,case rate,
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC,262-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45464.62617,,,45464.62617,45464.62617,56743.484,case rate,
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC,262-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,97548.58962,,,97548.58962,97548.58962,125503.2352,case rate,
OTHER NERVOUS SYSTEM & RELATED PROCEDURES,26-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50389.15951,,,50389.15951,30984.4164,54039.55192,case rate,
LAPAROSCOPIC CHOLECYSTECTOMY,263-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18050.11528,,,18050.11528,9202.422389,26193.3084,case rate,
LAPAROSCOPIC CHOLECYSTECTOMY,263-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23258.35313,,,23258.35313,11789.09603,33202.1868,case rate,
LAPAROSCOPIC CHOLECYSTECTOMY,263-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33681.04823,,,33681.04823,16421.85203,42120.7596,case rate,
LAPAROSCOPIC CHOLECYSTECTOMY,263-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74727.27906,,,74727.27906,34638.66505,77732.5608,case rate,
OTHER NERVOUS SYSTEM & RELATED PROCEDURES,26-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,117561.0831,,,117561.0831,68867.86622,117561.0831,case rate,
"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",264-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26979.57488,,,26979.57488,14046.71411,32412.3132,case rate,
"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",264-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29636.29781,,,29636.29781,16510.9197,35461.8252,case rate,
"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",264-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50553.17085,,,50553.17085,23031.41552,59220.958,case rate,
"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",264-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124541.8472,,,124541.8472,61248.86911,127597.1672,case rate,
HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,279-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9743.316977,,,9743.316977,5034.79757,12178.0512,case rate,
HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,279-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12877.54865,,,12877.54865,7568.278018,16218.6436,case rate,
HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,279-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21604.39655,,,21604.39655,11967.23137,28147.8364,case rate,
HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,279-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62602.25658,,,62602.25658,27713.65355,76812.06,case rate,
ALCOHOLIC LIVER DISEASE,280-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10448.55572,,,10448.55572,5038.508723,12535.494,case rate,
ALCOHOLIC LIVER DISEASE,280-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12686.01149,,,12686.01149,6806.254602,16174.9116,case rate,
ALCOHOLIC LIVER DISEASE,280-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20242.06919,,,20242.06919,12098.35878,26271.5904,case rate,
ALCOHOLIC LIVER DISEASE,280-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52937.46442,,,52937.46442,27156.9806,70743.8036,case rate,
MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,281-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13305.86402,,,13305.86402,7709.301832,15295.65834,case rate,
MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,281-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16906.40953,,,16906.40953,9416.432212,20184.27,case rate,
MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,281-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24067.77669,,,24067.77669,13007.59127,28570.7692,case rate,
MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,281-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44115.19903,,,44115.19903,20094.65644,50140.342,case rate,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10492.75351,,,10492.75351,4971.707969,12850.4436,case rate,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13418.65567,,,13418.65567,7026.44968,16732.3224,case rate,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23224.32705,,,23224.32705,11528.07827,28234.9108,case rate,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65602.63092,,,65602.63092,29874.78165,71666.3776,case rate,
OTHER DISORDERS OF THE LIVER,283-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10595.17283,,,10595.17283,6150.617572,12145.5564,case rate,
OTHER DISORDERS OF THE LIVER,283-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13223.68781,,,13223.68781,7450.758173,15542.5128,case rate,
OTHER DISORDERS OF THE LIVER,283-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19832.83331,,,19832.83331,10999.85749,24971.694,case rate,
OTHER DISORDERS OF THE LIVER,283-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46176.70624,,,46176.70624,23408.71607,53689.6604,case rate,
DISORDERS OF GALLBLADDER & BILIARY TRACT,284-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10999.67395,,,10999.67395,6745.639103,15552.5112,case rate,
DISORDERS OF GALLBLADDER & BILIARY TRACT,284-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14787.0018,,,14787.0018,9157.888553,20541.7128,case rate,
DISORDERS OF GALLBLADDER & BILIARY TRACT,284-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22102.00797,,,22102.00797,13476.43359,28450.4472,case rate,
DISORDERS OF GALLBLADDER & BILIARY TRACT,284-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49937.91265,,,49937.91265,24994.61546,61453.7944,case rate,
HIP JOINT REPLACEMENT,301-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30783.51451,,,30783.51451,30783.51451,38258.8328,case rate,
HIP JOINT REPLACEMENT,301-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34094.31668,,,34094.31668,34094.31668,39761.9028,case rate,
HIP JOINT REPLACEMENT,301-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47100.00483,,,47100.00483,47100.00483,52590.8644,case rate,
HIP JOINT REPLACEMENT,301-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79491.27188,,,79491.27188,79491.27188,125505.3084,case rate,
KNEE JOINT REPLACEMENT,302-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28871.83442,,,28871.83442,28871.83442,36759.9092,case rate,
KNEE JOINT REPLACEMENT,302-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32754.07819,,,32754.07819,32754.07819,41476.4392,case rate,
KNEE JOINT REPLACEMENT,302-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42988.16525,,,42988.16525,42988.16525,55843.7152,case rate,
KNEE JOINT REPLACEMENT,302-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,86380.10937,,,86380.10937,86380.10937,112840.1296,case rate,
DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK,303-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89811.92884,,,89811.92884,46210.04011,101563.7472,case rate,
DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK,303-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,107486.2324,,,107486.2324,74849.00781,121987.9788,case rate,
DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK,303-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153275.7716,,,153275.7716,89785.16158,167900.6316,case rate,
DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK,303-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,211667.6815,,,211667.6815,132386.7239,225864.774,case rate,
DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,304-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55619.56648,,,55619.56648,30469.80318,68644.0152,case rate,
DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,304-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66765.87761,,,66765.87761,37658.30654,81546.9504,case rate,
DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,304-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99400.82438,,,99400.82438,49603.271,115024.0932,case rate,
DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,304-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,177041.6671,,,177041.6671,73919.98251,190365.3704,case rate,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20173.8164,,,20173.8164,12742.86235,28220.3984,case rate,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26898.32155,,,26898.32155,15330.77304,39745.3172,case rate,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44668.6044,,,44668.6044,23719.21587,70113.5508,case rate,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,96438.95007,,,96438.95007,48347.66423,130648.9176,case rate,
HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT,308-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23127.22431,,,23127.22431,12426.1773,34324.5072,case rate,
HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT,308-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28365.61617,,,28365.61617,15106.86681,40488.5208,case rate,
HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT,308-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40017.1023,,,40017.1023,19182.94986,56923.8524,case rate,
HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT,308-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75417.65145,,,75417.65145,29528.40737,119598.7616,case rate,
HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT,309-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22449.79227,,,22449.79227,16540.60892,33297.1716,case rate,
HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT,309-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31419.31677,,,31419.31677,21734.98607,44285.4132,case rate,
HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT,309-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47903.02844,,,47903.02844,28908.64482,62982.4212,case rate,
HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT,309-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,94595.40239,,,94595.40239,56593.8462,119107.4132,case rate,
INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,310-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17783.3235,,,17783.3235,10533.48927,27105.6624,case rate,
INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,310-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23724.72716,,,23724.72716,15069.75528,36544.152,case rate,
INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,310-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34049.19601,,,34049.19601,23419.84953,52762.94,case rate,
INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,310-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91566.19817,,,91566.19817,48989.6937,141852.4904,case rate,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES",312-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30354.69758,,,30354.69758,18913.27274,30354.69758,case rate,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES",312-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42281.06069,,,42281.06069,26360.31976,46715.4156,case rate,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES",312-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82679.87306,,,82679.87306,37950.25058,93868.2764,case rate,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES",312-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,183380.53,,,183380.53,93185.81478,186635.6836,case rate,
KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,313-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20598.84151,,,20598.84151,13044.7028,31992.3804,case rate,
KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,313-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29376.68842,,,29376.68842,19132.23077,42118.26,case rate,
KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,313-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46836.403,,,46836.403,26401.14244,61450.1664,case rate,
KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,313-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,96823.85008,,,96823.85008,49239.578,134162.9916,case rate,
FOOT & TOE PROCEDURES,314-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18144.46946,,,18144.46946,11925.17164,27115.6608,case rate,
FOOT & TOE PROCEDURES,314-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21889.82645,,,21889.82645,12198.55991,28865.3808,case rate,
FOOT & TOE PROCEDURES,314-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32047.21438,,,32047.21438,16163.30837,42139.8632,case rate,
FOOT & TOE PROCEDURES,314-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73780.46716,,,73780.46716,30921.3268,79714.54,case rate,
"SHOULDER, UPPER ARM & FOREARM PROCEDURES",315-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16914.33423,,,16914.33423,11076.55465,23488.7412,case rate,
"SHOULDER, UPPER ARM & FOREARM PROCEDURES",315-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29485.08637,,,29485.08637,15271.3946,37593.984,case rate,
"SHOULDER, UPPER ARM & FOREARM PROCEDURES",315-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44437.14276,,,44437.14276,26054.76816,56016.036,case rate,
"SHOULDER, UPPER ARM & FOREARM PROCEDURES",315-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,94925.01002,,,94925.01002,41354.61493,106425.6488,case rate,
HAND & WRIST PROCEDURES,316-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15496.63423,,,15496.63423,10506.27414,19796.832,case rate,
HAND & WRIST PROCEDURES,316-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23061.8204,,,23061.8204,13457.87783,26730.7224,case rate,
HAND & WRIST PROCEDURES,316-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36801.27624,,,36801.27624,21581.59175,44223.4292,case rate,
HAND & WRIST PROCEDURES,316-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,76379.85133,,,76379.85133,43606.04775,78407.14905,case rate,
"TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES",317-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15855.81406,,,15855.81406,11239.84539,23246.28,case rate,
"TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES",317-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23570.28565,,,23570.28565,13519.73038,30067.6884,case rate,
"TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES",317-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42332.46095,,,42332.46095,21681.79288,54064.9096,case rate,
"TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES",317-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,101663.7195,,,101663.7195,56003.77287,130984.776,case rate,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES,320-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19715.10627,,,19715.10627,11227.47488,25820.868,case rate,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES,320-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28326.91552,,,28326.91552,13892.08273,35774.2752,case rate,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES,320-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44687.24251,,,44687.24251,22818.64275,52138.9068,case rate,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES,320-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91047.46089,,,91047.46089,40027.25921,103734.6352,case rate,
CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP,321-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32269.02593,,,32269.02593,19325.21072,42785.6532,case rate,
CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP,321-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42760.87663,,,42760.87663,22260.73275,51899.1948,case rate,
CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP,321-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75205.65049,,,75205.65049,30257.03041,76762.3032,case rate,
CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP,321-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,144667.1523,,,144667.1523,44892.58079,146454.9944,case rate,
FRACTURE OF FEMUR,340-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8026.04299,,,8026.04299,5316.845198,11410.674,case rate,
FRACTURE OF FEMUR,340-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10175.24361,,,10175.24361,6034.334778,14680.3292,case rate,
FRACTURE OF FEMUR,340-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15817.45446,,,15817.45446,8849.862854,35316.962,case rate,
FRACTURE OF FEMUR,340-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32665.60235,,,32665.60235,16870.90154,48058.8492,case rate,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9050.898206,,,9050.898206,4732.957126,12260.538,case rate,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10767.32957,,,10767.32957,5737.442538,15037.5936,case rate,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15314.16535,,,15314.16535,7997.534715,19946.2572,case rate,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45123.20171,,,45123.20171,15281.291,45123.20171,case rate,
"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",342-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8952.290775,,,8952.290775,4844.291716,12295.5324,case rate,
"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",342-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11889.04677,,,11889.04677,5866.095842,16562.3496,case rate,
"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",342-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17773.27216,,,17773.27216,9358.290815,23083.806,case rate,
"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",342-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46538.57445,,,46538.57445,15367.88457,54869.3112,case rate,
MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,343-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13843.60053,,,13843.60053,7009.130966,18679.5108,case rate,
MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,343-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17133.79846,,,17133.79846,8775.639794,21953.9868,case rate,
MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,343-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27749.87647,,,27749.87647,17239.54274,44503.3112,case rate,
MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,343-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52131.23081,,,52131.23081,21617.46623,79855.5176,case rate,
"OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS",344-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13003.01983,,,13003.01983,7847.851544,16670.6012,case rate,
"OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS",344-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17007.02321,,,17007.02321,9243.245072,23837.6536,case rate,
"OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS",344-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29181.17887,,,29181.17887,13350.25439,36973.4488,case rate,
"OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS",344-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56004.20568,,,56004.20568,25700.97158,71168.8096,case rate,
CONNECTIVE TISSUE DISORDERS,346-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11318.96943,,,11318.96943,7701.879526,15165.458,case rate,
CONNECTIVE TISSUE DISORDERS,346-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15390.14222,,,15390.14222,9745.487778,19948.3304,case rate,
CONNECTIVE TISSUE DISORDERS,346-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27661.74169,,,27661.74169,16054.44788,34475.2428,case rate,
CONNECTIVE TISSUE DISORDERS,346-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80639.79265,,,80639.79265,31037.60959,101058.134,case rate,
"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",347-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10887.02274,,,10887.02274,5435.602094,14497.68,case rate,
"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",347-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14005.82631,,,14005.82631,6772.854225,18282.0744,case rate,
"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",347-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20300.09009,,,20300.09009,9911.252612,24741.0408,case rate,
"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",347-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51751.56712,,,51751.56712,17676.22174,65415.6796,case rate,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",349-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8887.348303,,,8887.348303,5452.920808,12840.4452,case rate,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",349-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13547.6378,,,13547.6378,7583.12263,18227.5744,case rate,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",349-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22767.88399,,,22767.88399,12562.25291,32300.456,case rate,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",349-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50333.52606,,,50333.52606,18529.78693,74042.2648,case rate,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,351-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8903.217779,,,8903.217779,5078.094355,11600.6436,case rate,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,351-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11203.71008,,,11203.71008,6184.017949,14707.6464,case rate,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,351-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18402.53403,,,18402.53403,10279.89381,23939.2404,case rate,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,351-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44236.63764,,,44236.63764,17155.42327,63864.926,case rate,
SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,361-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24162.33149,,,24162.33149,14186.50087,33619.62,case rate,
SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,361-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32600.11818,,,32600.11818,18065.8928,41758.3176,case rate,
SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,361-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50195.1346,,,50195.1346,39833.0422,69240.7336,case rate,
SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,361-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,113823.3498,,,113823.3498,86944.89248,199037.566,case rate,
MASTECTOMY PROCEDURES,362-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20851.4892,,,20851.4892,13186.96366,31032.534,case rate,
MASTECTOMY PROCEDURES,362-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27884.39586,,,27884.39586,21263.66964,44682.8496,case rate,
MASTECTOMY PROCEDURES,362-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39053.61842,,,39053.61842,31751.38802,57599.7156,case rate,
MASTECTOMY PROCEDURES,362-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,98228.30879,,,98228.30879,60199.5084,98228.30879,case rate,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18594.85363,,,18594.85363,12076.09186,25605.9024,case rate,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32003.01659,,,32003.01659,22093.73086,47132.4576,case rate,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39029.92455,,,39029.92455,24995.85251,59822.9268,case rate,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,86414.37621,,,86414.37621,47162.56938,86414.37621,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",364-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15539.28721,,,15539.28721,7727.857597,18327.0672,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",364-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21946.64359,,,21946.64359,10091.86206,25320.948,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",364-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36214.00529,,,36214.00529,19288.09919,41942.9092,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",364-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77952.73514,,,77952.73514,30685.05006,110072.4076,case rate,
SKIN ULCERS,380-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10643.20257,,,10643.20257,5143.658058,14232.518,case rate,
SKIN ULCERS,380-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12785.30104,,,12785.30104,7255.304115,17296.7076,case rate,
SKIN ULCERS,380-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19707.18156,,,19707.18156,10987.48698,26905.9896,case rate,
SKIN ULCERS,380-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45491.69055,,,45491.69055,22432.68283,51670.3636,case rate,
MAJOR SKIN DISORDERS,381-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8606.733423,,,8606.733423,5139.946905,12325.174,case rate,
MAJOR SKIN DISORDERS,381-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12399.49822,,,12399.49822,10814.29984,18256.5992,case rate,
MAJOR SKIN DISORDERS,381-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22498.0427,,,22498.0427,16178.15298,39952.6372,case rate,
MAJOR SKIN DISORDERS,381-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82134.83377,,,82134.83377,46947.3225,122376.8496,case rate,
MALIGNANT BREAST DISORDERS,382-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9556.474454,,,9556.474454,7409.93549,14382.6984,case rate,
MALIGNANT BREAST DISORDERS,382-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13336.35909,,,13336.35909,8736.054162,17551.24968,case rate,
MALIGNANT BREAST DISORDERS,382-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22360.09261,,,22360.09261,12394.01397,31224.4652,case rate,
MALIGNANT BREAST DISORDERS,382-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42350.43699,,,42350.43699,22958.42951,59992.1884,case rate,
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS,383-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8194.548343,,,8194.548343,4840.580563,10528.3152,case rate,
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS,383-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11460.93203,,,11460.93203,6415.346486,14430.1908,case rate,
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS,383-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18461.91918,,,18461.91918,9314.99403,24503.1508,case rate,
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS,383-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45547.92588,,,45547.92588,19870.75021,57916.9152,case rate,
"CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE",384-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10747.74852,,,10747.74852,4469.465263,13467.8448,case rate,
"CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE",384-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12661.7358,,,12661.7358,5931.659545,16879.7988,case rate,
"CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE",384-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18458.74929,,,18458.74929,9802.392124,24593.5644,case rate,
"CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE",384-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46957.76136,,,46957.76136,23002.96335,46957.76136,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",385-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7533.988901,,,7533.988901,5467.76542,10365.8412,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",385-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10466.05026,,,10466.05026,6529.155178,13672.812,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",385-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17352.62069,,,17352.62069,11117.37734,22452.756,case rate,
"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",385-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55304.48414,,,55304.48414,21545.71727,60012.9204,case rate,
SPINAL DISORDERS & INJURIES,40-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17842.08671,,,17842.08671,10988.72403,20241.73525,case rate,
PITUITARY & ADRENAL PROCEDURES,401-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27998.71227,,,27998.71227,12116.91455,31822.4076,case rate,
PITUITARY & ADRENAL PROCEDURES,401-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37083.01462,,,37083.01462,35069.1588,56076.0264,case rate,
PITUITARY & ADRENAL PROCEDURES,401-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62558.82116,,,62558.82116,42096.84553,70371.2388,case rate,
PITUITARY & ADRENAL PROCEDURES,401-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,152983.7211,,,152983.7211,73754.21767,152983.7211,case rate,
SPINAL DISORDERS & INJURIES,40-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22116.99469,,,22116.99469,13329.22453,26192.80091,case rate,
SPINAL DISORDERS & INJURIES,40-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29592.12007,,,29592.12007,16477.51932,41182.00529,case rate,
PROCEDURES FOR OBESITY,403-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25862.79306,,,25862.79306,9434.987977,27653.0748,case rate,
PROCEDURES FOR OBESITY,403-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27646.77502,,,27646.77502,10330.6129,32104.8624,case rate,
PROCEDURES FOR OBESITY,403-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42857.1568,,,42857.1568,21879.72104,45797.6712,case rate,
PROCEDURES FOR OBESITY,403-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133223.3938,,,133223.3938,52066.23954,136348.1444,case rate,
SPINAL DISORDERS & INJURIES,40-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,68979.90032,,,68979.90032,39208.33145,68979.90032,case rate,
"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",404-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15028.4947,,,15028.4947,8439.161922,22673.8716,case rate,
"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",404-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19434.09014,,,19434.09014,13549.4196,33262.1772,case rate,
"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",404-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41269.54707,,,41269.54707,24232.59204,55818.5676,case rate,
"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",404-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91224.03139,,,91224.03139,55286.0244,116111.4192,case rate,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS",405-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25339.20064,,,25339.20064,14101.14435,31882.398,case rate,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS",405-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29805.00379,,,29805.00379,17777.65992,35949.2472,case rate,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS",405-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45671.67168,,,45671.67168,34643.61326,61057.8132,case rate,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS",405-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,113634.4409,,,113634.4409,64833.84291,173902.0892,case rate,
NERVOUS SYSTEM MALIGNANCY,41-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15256.36514,,,15256.36514,7717.961189,17041.99529,case rate,
NERVOUS SYSTEM MALIGNANCY,41-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16208.37324,,,16208.37324,9082.428442,18903.25248,case rate,
NERVOUS SYSTEM MALIGNANCY,41-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22952.96101,,,22952.96101,13337.88388,25176.54547,case rate,
NERVOUS SYSTEM MALIGNANCY,41-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43462.98561,,,43462.98561,21511.07984,43462.98561,case rate,
DIABETES,420-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7780.316884,,,7780.316884,5450.446706,10585.806,case rate,
DIABETES,420-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10122.55935,,,10122.55935,6132.061807,13602.8232,case rate,
DIABETES,420-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15829.19106,,,15829.19106,9246.956225,20261.3836,case rate,
DIABETES,420-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44471.61022,,,44471.61022,19479.8421,52659.28,case rate,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,42-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11035.26491,,,11035.26491,11035.26491,14139.69595,case rate,
"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",421-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6843.636573,,,6843.636573,6843.636573,12957.5,case rate,
"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",421-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10558.47843,,,10558.47843,10073.30629,18934.5356,case rate,
"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",421-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17142.46548,,,17142.46548,16778.12271,28767.7232,case rate,
"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",421-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43857.63602,,,43857.63602,28107.03577,66369.3516,case rate,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,42-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13719.63404,,,13719.63404,13719.63404,17410.25577,case rate,
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS,422-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5615.62798,,,5615.62798,4104.535218,8221.1844,case rate,
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS,422-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8734.210862,,,8734.210862,5026.138213,12235.542,case rate,
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS,422-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13384.8904,,,13384.8904,8599.978552,18700.264,case rate,
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS,422-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33604.89079,,,33604.89079,13498.70051,47067.8596,case rate,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,42-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20318.88869,,,20318.88869,20318.88869,25809.73345,case rate,
INBORN ERRORS OF METABOLISM,423-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11010.66823,,,11010.66823,7505.188417,17938.82382,case rate,
INBORN ERRORS OF METABOLISM,423-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13720.99829,,,13720.99829,12073.61776,22501.83327,case rate,
INBORN ERRORS OF METABOLISM,423-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21091.5376,,,21091.5376,21091.5376,33626.56297,case rate,
INBORN ERRORS OF METABOLISM,423-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75339.08651,,,75339.08651,55516.116,112746.8356,case rate,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,42-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56663.98268,,,56663.98268,33323.67984,58237.52061,case rate,
OTHER ENDOCRINE DISORDERS,424-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9278.387455,,,9278.387455,5590.233469,11885.598,case rate,
OTHER ENDOCRINE DISORDERS,424-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13400.67963,,,13400.67963,7811.977065,16539.8532,case rate,
OTHER ENDOCRINE DISORDERS,424-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20028.92467,,,20028.92467,13841.36364,24573.6396,case rate,
OTHER ENDOCRINE DISORDERS,424-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48011.54677,,,48011.54677,17585.91702,57699.2292,case rate,
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED,425-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7841.628035,,,7841.628035,4443.487192,10568.3088,case rate,
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED,425-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9931.864817,,,9931.864817,5879.703403,12940.4292,case rate,
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED,425-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15711.64458,,,15711.64458,9494.366425,20698.8288,case rate,
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED,425-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38531.67113,,,38531.67113,16985.94728,51643.412,case rate,
MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,43-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15568.03685,,,15568.03685,9343.446203,18083.03745,case rate,
MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,43-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19892.96077,,,19892.96077,11349.94293,24550.11751,case rate,
MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,43-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30096.29194,,,30096.29194,17613.13214,39363.56152,case rate,
MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,43-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,68791.15185,,,68791.15185,47495.33609,79098.92381,case rate,
KIDNEY TRANSPLANT,440-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89616.49955,,,89616.49955,76832.792,106417.9704,case rate,
KIDNEY TRANSPLANT,440-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99290.31985,,,99290.31985,85811.75377,119178.4284,case rate,
KIDNEY TRANSPLANT,440-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,118326.0279,,,118326.0279,90276.27083,138957.7632,case rate,
KIDNEY TRANSPLANT,440-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,205291.3619,,,205291.3619,116025.4874,215283.1612,case rate,
INTRACRANIAL HEMORRHAGE,44-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15276.22707,,,15276.22707,7552.196355,17220.009,case rate,
MAJOR BLADDER PROCEDURES,441-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27757.44005,,,27757.44005,23355.52288,36241.7004,case rate,
MAJOR BLADDER PROCEDURES,441-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43203.85772,,,43203.85772,24085.38297,55153.674,case rate,
MAJOR BLADDER PROCEDURES,441-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,57886.9957,,,57886.9957,29608.81569,72115.9596,case rate,
MAJOR BLADDER PROCEDURES,441-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124938.885,,,124938.885,79176.2122,142082.2632,case rate,
INTRACRANIAL HEMORRHAGE,44-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20152.7106,,,20152.7106,11254.69,22242.6994,case rate,
KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,442-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24814.18379,,,24814.18379,11636.93876,33899.5752,case rate,
KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,442-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29164.90815,,,29164.90815,13346.54324,39366.2004,case rate,
KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,442-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46621.3124,,,46621.3124,22750.60494,58375.0924,case rate,
KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,442-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,111753.8778,,,111753.8778,44083.54944,132185.1588,case rate,
INTRACRANIAL HEMORRHAGE,44-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27569.77496,,,27569.77496,16736.06298,31028.46426,case rate,
KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,443-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20967.25011,,,20967.25011,11062.94709,28535.4336,case rate,
KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,443-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25532.80425,,,25532.80425,12123.0998,33039.7128,case rate,
KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,443-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39350.82503,,,39350.82503,22086.30855,48587.2248,case rate,
KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,443-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,93921.08004,,,93921.08004,37955.19878,105065.6296,case rate,
INTRACRANIAL HEMORRHAGE,44-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50911.5883,,,50911.5883,25780.14284,50911.5883,case rate,
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY,444-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21281.04844,,,21281.04844,11144.59246,23252.19482,case rate,
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY,444-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27619.99152,,,27619.99152,17159.13442,36216.7308,case rate,
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY,444-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45638.56848,,,45638.56848,25838.28424,67018.2632,case rate,
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY,444-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,84629.09018,,,84629.09018,48597.54854,128246.0788,case rate,
OTHER BLADDER PROCEDURES,445-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16907.45278,,,16907.45278,8854.811058,23348.7636,case rate,
OTHER BLADDER PROCEDURES,445-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23370.34229,,,23370.34229,12878.93796,29707.746,case rate,
OTHER BLADDER PROCEDURES,445-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34196.03381,,,34196.03381,21110.27532,41720.8236,case rate,
OTHER BLADDER PROCEDURES,445-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69451.10942,,,69451.10942,50785.1072,79405.37778,case rate,
URETHRAL & TRANSURETHRAL PROCEDURES,446-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12745.53707,,,12745.53707,6557.607351,20209.266,case rate,
URETHRAL & TRANSURETHRAL PROCEDURES,446-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16645.43588,,,16645.43588,8358.753607,24608.562,case rate,
URETHRAL & TRANSURETHRAL PROCEDURES,446-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28222.44982,,,28222.44982,15461.90045,38683.8096,case rate,
URETHRAL & TRANSURETHRAL PROCEDURES,446-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59926.83536,,,59926.83536,25928.58896,68185.4748,case rate,
"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",447-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22163.7605,,,22163.7605,17965.69167,30457.626,case rate,
"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",447-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28347.86082,,,28347.86082,19581.28028,36876.5988,case rate,
"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",447-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42820.26177,,,42820.26177,23259.0329,60769.6384,case rate,
"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",447-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,107754.8299,,,107754.8299,52201.0781,158197.5992,case rate,
CVA & PRECEREBRAL OCCLUSION W INFARCT,45-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14284.45499,,,14284.45499,5539.514378,15426.35195,case rate,
CVA & PRECEREBRAL OCCLUSION W INFARCT,45-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17200.24563,,,17200.24563,7630.130568,19464.33364,case rate,
CVA & PRECEREBRAL OCCLUSION W INFARCT,45-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25261.31783,,,25261.31783,12318.55386,28245.59183,case rate,
CVA & PRECEREBRAL OCCLUSION W INFARCT,45-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55255.59171,,,55255.59171,23074.7123,55255.59171,case rate,
RENAL FAILURE,460-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10597.29946,,,10597.29946,10597.29946,10597.29946,case rate,
RENAL FAILURE,460-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13119.86412,,,13119.86412,13119.86412,13119.86412,case rate,
RENAL FAILURE,460-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16509.35161,,,16509.35161,16509.35161,16509.35161,case rate,
RENAL FAILURE,460-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47530.72771,,,47530.72771,47530.72771,47530.72771,case rate,
NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT,46-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13916.78871,,,13916.78871,5274.785464,15721.53923,case rate,
KIDNEY & URINARY TRACT MALIGNANCY,461-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10777.18028,,,10777.18028,6963.360079,16296.14042,case rate,
KIDNEY & URINARY TRACT MALIGNANCY,461-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12919.90069,,,12919.90069,8693.994428,18328.65129,case rate,
KIDNEY & URINARY TRACT MALIGNANCY,461-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20327.4554,,,20327.4554,13224.07519,31158.1228,case rate,
KIDNEY & URINARY TRACT MALIGNANCY,461-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44131.06851,,,44131.06851,23208.31381,48266.1692,case rate,
NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT,46-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15819.05947,,,15819.05947,5449.209655,18355.69135,case rate,
NEPHRITIS & NEPHROSIS,462-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8225.163794,,,8225.163794,6113.506042,12236.0264,case rate,
NEPHRITIS & NEPHROSIS,462-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11288.43423,,,11288.43423,8983.464362,15020.0964,case rate,
NEPHRITIS & NEPHROSIS,462-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20529.58559,,,20529.58559,17557.46484,29937.84867,case rate,
NEPHRITIS & NEPHROSIS,462-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51256.04221,,,51256.04221,42597.85119,83303.2492,case rate,
NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT,46-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21583.71207,,,21583.71207,7928.259859,23858.34274,case rate,
KIDNEY & URINARY TRACT INFECTIONS,463-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8023.13392,,,8023.13392,4507.813844,11468.1648,case rate,
KIDNEY & URINARY TRACT INFECTIONS,463-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10498.53153,,,10498.53153,5660.745376,14412.6936,case rate,
KIDNEY & URINARY TRACT INFECTIONS,463-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15159.50315,,,15159.50315,8570.289328,20464.5572,case rate,
KIDNEY & URINARY TRACT INFECTIONS,463-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31581.9438,,,31581.9438,15012.85094,45216.492,case rate,
NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT,46-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46957.48048,,,46957.48048,27606.03012,46957.48048,case rate,
URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8543.436079,,,8543.436079,4434.827835,12080.5668,case rate,
URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10813.63393,,,10813.63393,4939.544643,14842.6248,case rate,
URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17468.36154,,,17468.36154,10142.58115,24563.5692,case rate,
URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38074.48575,,,38074.48575,14394.32544,44967.708,case rate,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",466-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8157.232001,,,8157.232001,4913.566572,10413.6836,case rate,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",466-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12214.48139,,,12214.48139,5910.629678,14847.624,case rate,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",466-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20093.30539,,,20093.30539,9423.854518,24121.682,case rate,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",466-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40767.86296,,,40767.86296,16039.60327,48257.8764,case rate,
"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",468-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8959.733981,,,8959.733981,5075.620253,11188.2096,case rate,
"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",468-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12179.51236,,,12179.51236,6367.101497,15387.5376,case rate,
"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",468-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18104.32429,,,18104.32429,11291.80153,24658.6408,case rate,
"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",468-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42080.99695,,,42080.99695,28734.22063,58229.9684,case rate,
TRANSIENT ISCHEMIA,47-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11542.78723,,,11542.78723,4323.493245,13745.3618,case rate,
TRANSIENT ISCHEMIA,47-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12503.10122,,,12503.10122,5094.176018,15273.12496,case rate,
TRANSIENT ISCHEMIA,47-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16456.68742,,,16456.68742,7476.736244,19761.77426,case rate,
TRANSIENT ISCHEMIA,47-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37947.229,,,37947.229,19202.74267,37947.229,case rate,
MAJOR MALE PELVIC PROCEDURES,480-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22764.59373,,,22764.59373,10733.89153,31872.3996,case rate,
MAJOR MALE PELVIC PROCEDURES,480-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24858.98346,,,24858.98346,11931.3569,36631.638,case rate,
MAJOR MALE PELVIC PROCEDURES,480-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40972.94234,,,40972.94234,28808.44369,54628.758,case rate,
MAJOR MALE PELVIC PROCEDURES,480-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,94684.39986,,,94684.39986,53851.37,99928.78029,case rate,
"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",48-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11736.59146,,,11736.59146,5361.379034,13876.0554,case rate,
PENIS PROCEDURES,481-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14237.97007,,,14237.97007,14237.97007,15385.2172,case rate,
PENIS PROCEDURES,481-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24707.69177,,,24707.69177,24707.69177,25282.674,case rate,
PENIS PROCEDURES,481-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38096.21349,,,38096.21349,38096.21349,40522.7672,case rate,
PENIS PROCEDURES,481-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,94993.78444,,,94993.78444,42840.6048,94993.78444,case rate,
"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",48-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13216.7863,,,13216.7863,7298.6009,15581.83227,case rate,
TRANSURETHRAL PROSTATECTOMY,482-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11340.05517,,,11340.05517,6333.70112,17547.192,case rate,
TRANSURETHRAL PROSTATECTOMY,482-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14777.99371,,,14777.99371,7856.510901,21459.066,case rate,
TRANSURETHRAL PROSTATECTOMY,482-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29767.14576,,,29767.14576,15105.62976,48801.0548,case rate,
TRANSURETHRAL PROSTATECTOMY,482-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,60010.53631,,,60010.53631,40045.81497,67897.58062,case rate,
"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",48-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18065.90451,,,18065.90451,11413.03253,22003.84557,case rate,
TESTES & SCROTAL PROCEDURES,483-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12625.92415,,,12625.92415,10968.93122,23008.83432,case rate,
TESTES & SCROTAL PROCEDURES,483-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23392.25059,,,23392.25059,13637.25022,30185.1696,case rate,
TESTES & SCROTAL PROCEDURES,483-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45127.33459,,,45127.33459,29367.59074,65958.858,case rate,
TESTES & SCROTAL PROCEDURES,483-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,102854.6324,,,102854.6324,61402.26344,102854.6324,case rate,
"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",48-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52223.91979,,,52223.91979,33365.73957,52223.91979,case rate,
OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,484-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16516.31331,,,16516.31331,9928.571326,26938.1892,case rate,
OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,484-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23051.9095,,,23051.9095,10566.88964,34426.9908,case rate,
OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,484-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30404.4527,,,30404.4527,14999.24338,41285.8932,case rate,
OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,484-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75878.58853,,,75878.58853,44530.2628,93312.97992,case rate,
BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,49-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17685.19757,,,17685.19757,14547.71976,21605.00474,case rate,
BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,49-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36691.01246,,,36691.01246,15626.42823,40686.27093,case rate,
BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,49-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48513.15063,,,48513.15063,21618.70328,50639.26487,case rate,
BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,49-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89058.94123,,,89058.94123,49668.8347,89437.23856,case rate,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10441.39339,,,10441.39339,6494.51775,13909.85547,case rate,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13647.18817,,,13647.18817,9042.84281,19544.0564,case rate,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20311.5458,,,20311.5458,14146.91524,32750.3404,case rate,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40852.76767,,,40852.76767,30680.10185,45340.2444,case rate,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,50-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12733.80048,,,12733.80048,9092.32485,14141.94929,case rate,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8396.959405,,,8396.959405,4676.05278,10988.2416,case rate,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11221.52562,,,11221.52562,6501.940056,14745.1404,case rate,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17159.23777,,,17159.23777,9456.017844,23275.8164,case rate,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40599.35761,,,40599.35761,24962.45213,44213.0632,case rate,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,50-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21984.88281,,,21984.88281,13511.07102,27459.17687,case rate,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,50-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36206.94327,,,36206.94327,22689.98944,46443.54952,case rate,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,50-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,92389.06364,,,92389.06364,48152.21018,95431.11764,case rate,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",510-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22791.73836,,,22791.73836,14689.98063,32867.2404,case rate,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",510-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28759.84527,,,28759.84527,18325.67351,38461.3452,case rate,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",510-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56199.6751,,,56199.6751,39320.90309,58620.6192,case rate,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",510-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126587.9062,,,126587.9062,83533.10583,132877.6076,case rate,
VIRAL MENINGITIS,51-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9700.984998,,,9700.984998,5958.874667,9700.984998,case rate,
UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,511-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23299.52149,,,23299.52149,13689.20637,33049.7112,case rate,
UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,511-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29107.68975,,,29107.68975,16269.69475,40136.0772,case rate,
UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,511-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44953.37223,,,44953.37223,24194.24346,59110.5408,case rate,
UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,511-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100675.1373,,,100675.1373,70245.94104,129085.7248,case rate,
VIRAL MENINGITIS,51-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14247.23896,,,14247.23896,7971.556644,14971.17767,case rate,
UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,512-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21379.45525,,,21379.45525,11993.20945,30305.1504,case rate,
UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,512-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24250.70702,,,24250.70702,14775.33714,35854.2624,case rate,
UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,512-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39945.39874,,,39945.39874,20139.19028,56425.9704,case rate,
UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,512-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,98123.16097,,,98123.16097,66543.44739,155560.4888,case rate,
VIRAL MENINGITIS,51-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26314.18036,,,26314.18036,12687.19506,28606.12591,case rate,
UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15479.38044,,,15479.38044,8623.482521,23416.2528,case rate,
UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18292.67151,,,18292.67151,11237.37128,28187.9892,case rate,
UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31694.25395,,,31694.25395,17451.07846,44782.8336,case rate,
UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,87886.60622,,,87886.60622,48770.73568,99546.7712,case rate,
VIRAL MENINGITIS,51-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66604.57471,,,66604.57471,38400.53714,66604.57471,case rate,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13284.35696,,,13284.35696,8475.036401,20611.7544,case rate,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18463.72481,,,18463.72481,13920.5349,28765.3968,case rate,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31396.62603,,,31396.62603,20611.7544,55523.6148,case rate,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99535.28358,,,99535.28358,64279.64406,99535.28358,case rate,
DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12553.05697,,,12553.05697,8457.717687,16377.3792,case rate,
DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16054.65399,,,16054.65399,10204.4337,20789.1732,case rate,
DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28108.6751,,,28108.6751,17614.36919,42208.2788,case rate,
DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54112.30726,,,54112.30726,40275.90646,74713.92807,case rate,
OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,518-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14612.3573,,,14612.3573,8877.077976,19889.3172,case rate,
OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,518-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20146.23039,,,20146.23039,11375.921,28867.8804,case rate,
OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,518-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39090.19245,,,39090.19245,24019.81927,48604.50066,case rate,
OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,518-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,98865.69599,,,98865.69599,53627.3979,123933.8228,case rate,
UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,519-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16294.62214,,,16294.62214,8666.779306,22143.9564,case rate,
UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,519-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18835.96535,,,18835.96535,11551.58224,28140.4968,case rate,
UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,519-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34243.22093,,,34243.22093,24517.11377,45487.7208,case rate,
UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,519-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90668.07808,,,90668.07808,55004.23566,125403.7216,case rate,
NONTRAUMATIC STUPOR & COMA,52-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10816.864,,,10816.864,4157.728411,12904.86673,case rate,
NONTRAUMATIC STUPOR & COMA,52-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12564.7735,,,12564.7735,6290.404335,14583.60354,case rate,
NONTRAUMATIC STUPOR & COMA,52-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17904.76211,,,17904.76211,9645.286647,18982.11931,case rate,
NONTRAUMATIC STUPOR & COMA,52-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49467.56624,,,49467.56624,25354.5973,49467.56624,case rate,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9848.504924,,,9848.504924,6657.808482,13587.62814,case rate,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13116.63405,,,13116.63405,9229.637511,17554.6908,case rate,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22144.19951,,,22144.19951,12299.99809,30100.7908,case rate,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46753.00298,,,46753.00298,16086.6112,51977.1972,case rate,
SEIZURE,53-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9711.096523,,,9711.096523,5759.709456,11613.70405,case rate,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8983.748853,,,8983.748853,4797.283778,11913.0936,case rate,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12507.83599,,,12507.83599,6639.252717,15552.5112,case rate,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21100.8065,,,21100.8065,9031.709351,24028.388,case rate,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45870.35111,,,45870.35111,26913.28156,45870.35111,case rate,
SEIZURE,53-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11832.61082,,,11832.61082,6668.941941,14387.56313,case rate,
MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8462.002191,,,8462.002191,4301.226327,9995.807368,case rate,
MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10191.59458,,,10191.59458,5490.032338,12453.0072,case rate,
MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16657.5336,,,16657.5336,8175.670059,20124.5524,case rate,
MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37029.06642,,,37029.06642,21329.0816,41303.68554,case rate,
SEIZURE,53-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17613.43383,,,17613.43383,10600.29002,19211.95979,case rate,
SEIZURE,53-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48383.72713,,,48383.72713,28097.13936,49100.23502,case rate,
CESAREAN DELIVERY,540-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14674.8,,,14674.8,8545.548308,16608.4052,case rate,
CESAREAN DELIVERY,540-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14674.8,,,14674.8,10912.02687,19136.9376,case rate,
CESAREAN DELIVERY,540-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14674.8,,,14674.8,14180.31561,24389.1248,case rate,
CESAREAN DELIVERY,540-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14674.8,,,14674.8,14674.8,56092.4992,case rate,
MIGRAINE & OTHER HEADACHES,54-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10128.71855,,,10128.71855,4755.224044,12057.61164,case rate,
VAGINAL DELIVERY W STERILIZATION &/OR D&C,541-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,8247.419017,16309.89,case rate,
VAGINAL DELIVERY W STERILIZATION &/OR D&C,541-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,16997.28,case rate,
VAGINAL DELIVERY W STERILIZATION &/OR D&C,541-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,20924.1516,case rate,
VAGINAL DELIVERY W STERILIZATION &/OR D&C,541-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,28137.9972,case rate,
MIGRAINE & OTHER HEADACHES,54-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12032.11281,,,12032.11281,6539.051586,14419.10986,case rate,
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,542-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,7415.735358,12337.6132,case rate,
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,542-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,8497.303319,14060.4424,case rate,
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,542-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,25326.2112,case rate,
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,542-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,41235.9012,case rate,
MIGRAINE & OTHER HEADACHES,54-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15929.96524,,,15929.96524,9390.454141,18346.678,case rate,
MIGRAINE & OTHER HEADACHES,54-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36686.71908,,,36686.71908,21545.71727,37326.54397,case rate,
"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",544-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9955.25775,,,9955.25775,9949.2868,9955.25775,case rate,
"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",544-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11827.33437,,,11827.33437,11827.33437,12831.0348,case rate,
"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",544-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22509.83948,,,22509.83948,22509.83948,22792.7608,case rate,
"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",544-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55482.90039,,,55482.90039,55482.90039,59513.2792,case rate,
ECTOPIC PREGNANCY PROCEDURE,545-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14081.62262,,,14081.62262,14081.62262,14410.8132,case rate,
ECTOPIC PREGNANCY PROCEDURE,545-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16112.01282,,,16112.01282,16112.01282,16274.62,case rate,
ECTOPIC PREGNANCY PROCEDURE,545-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20079.82336,,,20079.82336,20079.82336,22832.1516,case rate,
ECTOPIC PREGNANCY PROCEDURE,545-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30491.08279,,,30491.08279,24362.1732,30491.08279,case rate,
OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,546-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10886.94249,,,10886.94249,10886.94249,11929.1928,case rate,
OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,546-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15506.98651,,,15506.98651,15506.98651,16160.594,case rate,
OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,546-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30759.09839,,,30759.09839,30759.09839,34703.2948,case rate,
OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,546-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89227.98828,,,89227.98828,89227.98828,89307.2364,case rate,
HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE,55-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12770.29426,,,12770.29426,5866.095842,15117.64464,case rate,
HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE,55-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17506.72113,,,17506.72113,8598.741501,20645.08276,case rate,
HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE,55-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27519.95965,,,27519.95965,14370.82147,30954.10411,case rate,
HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE,55-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,67919.11308,,,67919.11308,31019.05383,67919.11308,case rate,
VAGINAL DELIVERY,560-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,6405.450078,10977.594,case rate,
VAGINAL DELIVERY,560-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,7140.828122,12132.3664,case rate,
VAGINAL DELIVERY,560-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9198.711236,15059.7248,case rate,
VAGINAL DELIVERY,560-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,35173.9112,case rate,
"BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA",56-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13228.48276,,,13228.48276,8596.267399,14094.62919,case rate,
POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE,561-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5427.682017,,,5427.682017,3781.664907,7857.428,case rate,
POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE,561-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8121.480538,,,8121.480538,4975.419122,9898.416,case rate,
POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE,561-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12979.74727,,,12979.74727,6473.487883,15482.5224,case rate,
POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE,561-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34523.97624,,,34523.97624,14762.96663,34523.97624,case rate,
"BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA",56-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18815.28086,,,18815.28086,10099.28436,19876.6945,case rate,
"BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA",56-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29532.0528,,,29532.0528,15516.33069,30363.72955,case rate,
PRETERM LABOR,563-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5608.586025,,,5608.586025,5608.586025,7214.736,case rate,
PRETERM LABOR,563-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7528.39145,,,7528.39145,7528.39145,8682.5616,case rate,
PRETERM LABOR,563-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13947.44429,,,13947.44429,12327.2472,13947.44429,case rate,
PRETERM LABOR,563-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21166.09004,,,21166.09004,12327.2472,21166.09004,case rate,
"BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA",56-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74596.21043,,,74596.21043,31626.44587,74596.21043,case rate,
"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5782.127079,,,5782.127079,4097.112912,7981.2228,case rate,
"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6760.136242,,,6760.136242,4789.861472,10675.7916,case rate,
"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9790.102842,,,9790.102842,9176.444318,14905.1148,case rate,
"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49092.57713,,,49092.57713,15036.9196,49092.57713,case rate,
FALSE LABOR,565-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2649.48035,,,2649.48035,2649.48035,4718.6032,case rate,
FALSE LABOR,565-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3976.818624,,,3976.818624,3976.818624,5854.7168,case rate,
FALSE LABOR,565-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6322.67235,,,6322.67235,5958.3768,6322.67235,case rate,
FALSE LABOR,565-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6954.943597,,,6954.943597,5958.3768,6954.943597,case rate,
OTHER ANTEPARTUM DIAGNOSES,566-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5303.635273,,,5303.635273,3870.732579,7063.3924,case rate,
OTHER ANTEPARTUM DIAGNOSES,566-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7089.081803,,,7089.081803,5616.21154,9244.3988,case rate,
OTHER ANTEPARTUM DIAGNOSES,566-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11190.18792,,,11190.18792,7637.552874,13602.2652,case rate,
OTHER ANTEPARTUM DIAGNOSES,566-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35116.00202,,,35116.00202,13598.90164,35116.00202,case rate,
"CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA",57-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12841.2555,,,12841.2555,4092.164708,12841.2555,case rate,
"CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA",57-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16916.36055,,,16916.36055,6427.716996,18427.79816,case rate,
"CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA",57-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24974.44343,,,24974.44343,11096.34747,26134.21412,case rate,
"CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA",57-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,63082.27314,,,63082.27314,22070.22689,63082.27314,case rate,
"NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE",580-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,7308.8304,per diem,
"NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE",580-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,9346.0044,per diem,
"NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE",580-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,15332.5464,per diem,
"NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE",580-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,25158.51877,per diem,
OTHER DISORDERS OF NERVOUS SYSTEM,58-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11983.36082,,,11983.36082,6548.947994,16023.48652,case rate,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2088.142088,3106.94,per diem,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2351.633951,3852.0056,per diem,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2710.378741,5844.0648,per diem,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,10254.0472,per diem,
OTHER DISORDERS OF NERVOUS SYSTEM,58-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14680.04834,,,14680.04834,10462.97736,20723.94959,case rate,
OTHER DISORDERS OF NERVOUS SYSTEM,58-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20733.86247,,,20733.86247,15280.05395,28038.28473,case rate,
NEONATE W ECMO,583-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,374287.6044,per diem,
NEONATE W ECMO,583-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,433113.1908,per diem,
NEONATE W ECMO,583-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,602569.6213,per diem,
NEONATE W ECMO,583-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,741583.8276,per diem,
OTHER DISORDERS OF NERVOUS SYSTEM,58-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47556.34758,,,47556.34758,27114.92087,48663.08745,case rate,
NEONATE BWT <1500G W MAJOR PROCEDURE,588-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,400220.894,per diem,
NEONATE BWT <1500G W MAJOR PROCEDURE,588-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,400220.894,per diem,
NEONATE BWT <1500G W MAJOR PROCEDURE,588-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,523155.4344,per diem,
NEONATE BWT <1500G W MAJOR PROCEDURE,588-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,608300.1564,per diem,
NEONATE BWT <500G OR GA <24 WEEKS,589-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,284033.2549,per diem,
NEONATE BWT <500G OR GA <24 WEEKS,589-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,275285.7968,per diem,
NEONATE BWT <500G OR GA <24 WEEKS,589-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,250260.225,per diem,
NEONATE BWT <500G OR GA <24 WEEKS,589-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,1664.7336,47416.99153,per diem,
NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,591-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2247.721667,214623.6845,per diem,
NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,591-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,297672.7098,per diem,
NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,591-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,316172.6148,per diem,
NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,591-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,453416.6724,per diem,
NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,593-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2595.332998,223963.6496,per diem,
NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,593-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,243214.037,per diem,
NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,593-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,282328.376,per diem,
NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,593-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,396726.5136,per diem,
NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,602-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,134606.6564,per diem,
NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,602-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,196622.288,per diem,
NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,602-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,231412.6572,per diem,
NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,602-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,313501.0112,per diem,
NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION,603-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3035.723154,107271.5144,per diem,
NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION,603-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,143019.702,per diem,
NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION,603-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,186808.4802,per diem,
NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION,603-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,318901.4676,per diem,
NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,607-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,125246.1584,per diem,
NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,607-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,155042.1888,per diem,
NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,607-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,189679.1412,per diem,
NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,607-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,256779.1318,per diem,
NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION,608-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,87994.9008,per diem,
NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION,608-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,117882.152,per diem,
NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION,608-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,141466.8752,per diem,
NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION,608-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,235257.5006,per diem,
NEONATE BWT 1500-2499G W MAJOR PROCEDURE,609-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,115776.5064,per diem,
NEONATE BWT 1500-2499G W MAJOR PROCEDURE,609-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,119983.4885,per diem,
NEONATE BWT 1500-2499G W MAJOR PROCEDURE,609-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,191851.4507,per diem,
NEONATE BWT 1500-2499G W MAJOR PROCEDURE,609-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,430881.039,per diem,
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY,611-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,51933.66,per diem,
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY,611-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,83651.5468,per diem,
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY,611-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,129902.5656,per diem,
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY,611-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,216541.2751,per diem,
NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,612-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,72939.3224,per diem,
NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,612-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,94332.6732,per diem,
NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,612-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,131503.076,per diem,
NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,612-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,175674.6752,per diem,
NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,613-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,55232.1212,per diem,
NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,613-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,83500.2032,per diem,
NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,613-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,109408.5733,per diem,
NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,613-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,182804.2986,per diem,
NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,614-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,41352.0472,per diem,
NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,614-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,68380.3556,per diem,
NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,614-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,104408.4252,per diem,
NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,614-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,156676.8445,per diem,
NEONATE BWT 2000-2499G W MAJOR ANOMALY,621-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,22326.0729,per diem,
NEONATE BWT 2000-2499G W MAJOR ANOMALY,621-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,53971.95178,per diem,
NEONATE BWT 2000-2499G W MAJOR ANOMALY,621-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,99259.5389,per diem,
NEONATE BWT 2000-2499G W MAJOR ANOMALY,621-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,182153.0839,per diem,
NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND,622-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,40164.1036,per diem,
NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND,622-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,54533.4528,per diem,
NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND,622-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,74755.4456,per diem,
NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND,622-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,128510.1195,per diem,
NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,623-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,30162.9868,per diem,
NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,623-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,45294.34714,per diem,
NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,623-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,81926.863,per diem,
NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,623-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,128086.4919,per diem,
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,625-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,33167.0536,per diem,
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,625-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,53639.9036,per diem,
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,625-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,72902.24431,per diem,
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,625-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,136351.7357,per diem,
"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",626-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2371.426767,4318.4756,per diem,
"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",626-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,8636.9512,per diem,
"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",626-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,27737.3428,per diem,
"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",626-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,63318.7978,per diem,
NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,630-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,71500.5216,per diem,
NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,630-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,135353.34,per diem,
NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,630-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,213335.8608,per diem,
NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,630-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,441526.8444,per diem,
NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE,631-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,37594.69119,per diem,
NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE,631-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,86071.2264,per diem,
NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE,631-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,140342.5416,per diem,
NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE,631-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,365451.5184,per diem,
NEONATE BIRTHWT >2499G W MAJOR ANOMALY,633-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,8596.48447,per diem,
NEONATE BIRTHWT >2499G W MAJOR ANOMALY,633-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,28784.13961,per diem,
NEONATE BIRTHWT >2499G W MAJOR ANOMALY,633-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,70693.97307,per diem,
NEONATE BIRTHWT >2499G W MAJOR ANOMALY,633-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,165647.3831,per diem,
"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",634-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,16670.6012,per diem,
"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",634-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,30082.0623,per diem,
"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",634-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,46692.6104,per diem,
"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",634-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,111116.6035,per diem,
NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,636-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,20470.7768,per diem,
NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,636-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,27780.88,per diem,
NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,636-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,53190.04349,per diem,
NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,636-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,95108.8903,per diem,
NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,639-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,14743.59053,per diem,
NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,639-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,27456.92353,per diem,
NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,639-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,45195.20027,per diem,
NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,639-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,79492.7076,per diem,
"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",640-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3283.28,,,3283.28,1692.285768,3626.0268,case rate,
"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",640-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3283.28,,,3283.28,2154.942842,5037.876,case rate,
"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",640-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3283.28,,,3283.28,3283.28,11197.3532,case rate,
"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",640-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3283.28,,,3283.28,3283.28,71164.92072,case rate,
SPLENECTOMY,650-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24474.84582,,,24474.84582,17516.64216,33414.6528,case rate,
SPLENECTOMY,650-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33982.90935,,,33982.90935,22954.71836,44220.4236,case rate,
SPLENECTOMY,650-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51075.39902,,,51075.39902,35121.11494,65164.572,case rate,
SPLENECTOMY,650-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,110425.7972,,,110425.7972,55417.4107,118234.596,case rate,
OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,651-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19476.1613,,,19476.1613,10462.97736,25815.8688,case rate,
OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,651-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27535.36769,,,27535.36769,16851.10872,37791.4524,case rate,
OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,651-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44404.92231,,,44404.92231,32278.37174,54677.24657,case rate,
OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,651-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,121197.701,,,121197.701,78199.0308,158835.5423,case rate,
MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL,660-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12374.46016,,,12374.46016,9472.099507,15356.49847,case rate,
MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL,660-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15196.83956,,,15196.83956,10841.51496,18656.7268,case rate,
MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL,660-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24988.62765,,,24988.62765,15981.46187,31547.8844,case rate,
MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL,660-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,76904.10581,,,76904.10581,45934.17773,103203.896,case rate,
COAGULATION & PLATELET DISORDERS,661-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16654.66465,,,16654.66465,10362.77623,20931.0272,case rate,
COAGULATION & PLATELET DISORDERS,661-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20397.61414,,,20397.61414,12003.10585,24584.0056,case rate,
COAGULATION & PLATELET DISORDERS,661-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37329.6636,,,37329.6636,17730.65198,40547.6456,case rate,
COAGULATION & PLATELET DISORDERS,661-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,76971.11472,,,76971.11472,41091.12307,94664.3852,case rate,
SICKLE CELL ANEMIA CRISIS,662-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10640.49413,,,10640.49413,7726.620546,13865.5616,case rate,
SICKLE CELL ANEMIA CRISIS,662-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14397.24665,,,14397.24665,11199.0227,20010.5264,case rate,
SICKLE CELL ANEMIA CRISIS,662-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22826.30613,,,22826.30613,14193.92317,31941.7924,case rate,
SICKLE CELL ANEMIA CRISIS,662-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58402.92422,,,58402.92422,19756.94152,68670.6036,case rate,
OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS,663-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8942.038813,,,8942.038813,5320.556351,11645.6364,case rate,
OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS,663-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11587.08534,,,11587.08534,7001.70866,16472.364,case rate,
OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS,663-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17183.37302,,,17183.37302,9911.252612,23020.8128,case rate,
OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS,663-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37636.1993,,,37636.1993,20617.92902,48832.1528,case rate,
MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,680-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28082.39316,,,28082.39316,15089.5481,38263.8768,case rate,
MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,680-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39077.07154,,,39077.07154,20636.48478,50486.9208,case rate,
MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,680-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,68573.79419,,,68573.79419,38646.71029,83031.7128,case rate,
MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,680-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,154900.6776,,,154900.6776,98899.75335,185474.6916,case rate,
OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,681-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20629.77796,,,20629.77796,11471.17392,28300.4712,case rate,
OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,681-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28953.0075,,,28953.0075,16049.49967,37141.5564,case rate,
OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,681-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52482.18499,,,52482.18499,29709.01682,79181.7276,case rate,
OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,681-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,140315.3847,,,140315.3847,68121.92447,185990.9184,case rate,
ACUTE LEUKEMIA,690-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20685.75248,,,20685.75248,20674.1916,32434.54717,case rate,
ACUTE LEUKEMIA,690-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31863.76243,,,31863.76243,31812.00352,56364.0884,case rate,
ACUTE LEUKEMIA,690-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65733.49893,,,65733.49893,57289.06886,125696.0428,case rate,
ACUTE LEUKEMIA,690-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,146223.8055,,,146223.8055,97509.30802,181469.2692,case rate,
"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",691-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17553.86812,,,17553.86812,11648.07222,23067.42111,case rate,
"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",691-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22931.55427,,,22931.55427,15364.17342,30766.288,case rate,
"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",691-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35632.01079,,,35632.01079,23463.14632,52093.2964,case rate,
"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",691-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81875.68582,,,81875.68582,43705.01183,131291.6096,case rate,
RADIOTHERAPY,692-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16832.05772,,,16832.05772,12354.1988,19865.42781,case rate,
RADIOTHERAPY,692-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31897.32707,,,31897.32707,15810.74883,34570.7116,case rate,
RADIOTHERAPY,692-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45424.56126,,,45424.56126,28178.78473,57713.7416,case rate,
RADIOTHERAPY,692-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81233.3833,,,81233.3833,47680.89374,94797.92966,case rate,
CHEMOTHERAPY,693-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14789.91087,,,14789.91087,14789.91087,14789.91087,case rate,
CHEMOTHERAPY,693-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17344.39504,,,17344.39504,17344.39504,17344.39504,case rate,
CHEMOTHERAPY,693-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33891.82537,,,33891.82537,33891.82537,33891.82537,case rate,
CHEMOTHERAPY,693-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,118665.065,,,118665.065,118665.065,118665.065,case rate,
LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,694-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11535.7854,,,11535.7854,6308.9601,14902.6152,case rate,
LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,694-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14964.45505,,,14964.45505,8468.851146,20348.458,case rate,
LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,694-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24597.92957,,,24597.92957,13250.05326,33604.4988,case rate,
LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,694-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,53247.08975,,,53247.08975,24004.97466,70103.1848,case rate,
ORBITAL PROCEDURES,70-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17171.69662,,,17171.69662,17171.69662,17171.69662,case rate,
ORBITAL PROCEDURES,70-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24603.64739,,,24603.64739,24603.64739,24603.64739,case rate,
ORBITAL PROCEDURES,70-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44276.02043,,,44276.02043,44276.02043,44276.02043,case rate,
ORBITAL PROCEDURES,70-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,85525.86608,,,85525.86608,85525.86608,85525.86608,case rate,
INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,710-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21338.40727,,,21338.40727,8477.510503,24978.5028,case rate,
INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,710-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31491.54195,,,31491.54195,13063.25856,36136.7172,case rate,
INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,710-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51836.69252,,,51836.69252,22055.38228,61690.1392,case rate,
INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,710-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,116497.8682,,,116497.8682,54399.31773,131034.5328,case rate,
"POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE",711-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20219.65933,,,20219.65933,11346.23177,25383.438,case rate,
"POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE",711-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29039.21627,,,29039.21627,15597.97606,33192.1884,case rate,
"POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE",711-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51068.91881,,,51068.91881,27400.67965,59602.4268,case rate,
"POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE",711-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,121608.7827,,,121608.7827,59994.4994,125136.2788,case rate,
SEPTICEMIA & DISSEMINATED INFECTIONS,720-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10626.08922,,,10626.08922,4986.552581,13955.2668,case rate,
SEPTICEMIA & DISSEMINATED INFECTIONS,720-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14338.022,,,14338.022,6671.416043,17947.128,case rate,
SEPTICEMIA & DISSEMINATED INFECTIONS,720-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24576.90401,,,24576.90401,10689.35769,30849.216,case rate,
SEPTICEMIA & DISSEMINATED INFECTIONS,720-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56429.07029,,,56429.07029,22367.11913,66348.6196,case rate,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11103.03621,,,11103.03621,6469.77673,13525.3356,case rate,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14833.26604,,,14833.26604,8070.520724,17827.1472,case rate,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24920.25449,,,24920.25449,14030.63244,29679.9312,case rate,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50938.69281,,,50938.69281,27841.06981,58692.292,case rate,
FEVER,722-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6893.792946,,,6893.792946,4348.234265,10643.8088,case rate,
FEVER,722-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10609.4373,,,10609.4373,6099.898481,13842.7848,case rate,
FEVER,722-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15842.83359,,,15842.83359,8863.470415,18866.9808,case rate,
FEVER,722-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30130.55878,,,30130.55878,15852.80857,37151.744,case rate,
VIRAL ILLNESS,723-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6550.141536,,,6550.141536,4109.483422,9532.5736,case rate,
VIRAL ILLNESS,723-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9585.40465,,,9585.40465,6531.62928,12627.9792,case rate,
VIRAL ILLNESS,723-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16109.22412,,,16109.22412,9405.298753,19313.36,case rate,
VIRAL ILLNESS,723-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58763.36799,,,58763.36799,23387.68621,58763.36799,case rate,
OTHER INFECTIOUS & PARASITIC DISEASES,724-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11775.21187,,,11775.21187,6918.826243,13605.3228,case rate,
OTHER INFECTIOUS & PARASITIC DISEASES,724-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14322.25284,,,14322.25284,7115.517352,16299.8916,case rate,
OTHER INFECTIOUS & PARASITIC DISEASES,724-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23459.05888,,,23459.05888,10074.54334,28255.6428,case rate,
OTHER INFECTIOUS & PARASITIC DISEASES,724-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,60298.21321,,,60298.21321,20912.34716,75062.2792,case rate,
EYE PROCEDURES EXCEPT ORBIT,73-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14537.08262,,,14537.08262,10326.90175,20336.37545,case rate,
EYE PROCEDURES EXCEPT ORBIT,73-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18247.4104,,,18247.4104,14159.28575,28132.92493,case rate,
EYE PROCEDURES EXCEPT ORBIT,73-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29582.30949,,,29582.30949,28636.4936,47349.39139,case rate,
EYE PROCEDURES EXCEPT ORBIT,73-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,61405.64588,,,61405.64588,53497.50755,97375.74833,case rate,
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,740-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27109.86108,,,27109.86108,4163,62735.032,case rate,
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,740-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27651.65022,,,27651.65022,4163,62735.032,case rate,
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,740-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51990.43184,,,51990.43184,4163,62735.032,case rate,
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,740-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75876.70265,,,75876.70265,4163,102414.2121,case rate,
SCHIZOPHRENIA,750-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13011.2856,,,13011.2856,4163,30820.1912,case rate,
SCHIZOPHRENIA,750-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14401.25916,,,14401.25916,4163,35922.3364,case rate,
SCHIZOPHRENIA,750-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20815.19604,,,20815.19604,4163,44998.806,case rate,
SCHIZOPHRENIA,750-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38378.53369,,,38378.53369,4163,67191.66212,case rate,
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,751-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7159.059976,,,7159.059976,4163,17790.1292,case rate,
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,751-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10103.35949,,,10103.35949,4163,21897.1384,case rate,
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,751-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16409.21942,,,16409.21942,4163,37218.0864,case rate,
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,751-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32216.3818,,,32216.3818,4163,47849.456,case rate,
DISORDERS OF PERSONALITY & IMPULSE CONTROL,752-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6510.096687,,,6510.096687,4163,19658.0824,case rate,
DISORDERS OF PERSONALITY & IMPULSE CONTROL,752-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8708.871862,,,8708.871862,4163,19658.0824,case rate,
DISORDERS OF PERSONALITY & IMPULSE CONTROL,752-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18661.82242,,,18661.82242,4163,39719.23351,case rate,
DISORDERS OF PERSONALITY & IMPULSE CONTROL,752-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20025.29335,,,20025.29335,4163,62910.22861,case rate,
BIPOLAR DISORDERS,753-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7943.88685,,,7943.88685,4163,17174.3888,case rate,
BIPOLAR DISORDERS,753-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10679.2951,,,10679.2951,4163,21279.3248,case rate,
BIPOLAR DISORDERS,753-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17282.92339,,,17282.92339,4163,34187.068,case rate,
BIPOLAR DISORDERS,753-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29351.18892,,,29351.18892,4163,44570.94753,case rate,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5731.388891,,,5731.388891,4163,14365.2028,case rate,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7636.087215,,,7636.087215,4163,14365.2028,case rate,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11410.25403,,,11410.25403,4163,17667.8104,case rate,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25196.51579,,,25196.51579,4163,36008.34124,case rate,
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5134.748731,,,5134.748731,4163,10579.5396,case rate,
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8160.221321,,,8160.221321,4163,16724.5044,case rate,
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12505.10748,,,12505.10748,4163,19860.85381,case rate,
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18869.22906,,,18869.22906,4163,32470.60058,case rate,
ACUTE ANXIETY & DELIRIUM STATES,756-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8111.730139,,,8111.730139,4163,10119.74096,case rate,
ACUTE ANXIETY & DELIRIUM STATES,756-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10261.13138,,,10261.13138,4163,12528.55928,case rate,
ACUTE ANXIETY & DELIRIUM STATES,756-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12845.64919,,,12845.64919,4163,18559.2864,case rate,
ACUTE ANXIETY & DELIRIUM STATES,756-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29601.60966,,,29601.60966,4163,34512.12481,case rate,
ORGANIC MENTAL HEALTH DISTURBANCES,757-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11523.52718,,,11523.52718,4163,16728.6508,case rate,
ORGANIC MENTAL HEALTH DISTURBANCES,757-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12920.34207,,,12920.34207,4163,20286.39935,case rate,
ORGANIC MENTAL HEALTH DISTURBANCES,757-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16792.79531,,,16792.79531,4163,26792.18882,case rate,
ORGANIC MENTAL HEALTH DISTURBANCES,757-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31596.30858,,,31596.30858,4163,60416.49846,case rate,
CHILDHOOD BEHAVIORAL DISORDERS,758-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8645.454143,,,8645.454143,4163,11153.816,case rate,
CHILDHOOD BEHAVIORAL DISORDERS,758-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11084.49841,,,11084.49841,4163,23445.8188,case rate,
CHILDHOOD BEHAVIORAL DISORDERS,758-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15984.43506,,,15984.43506,4163,23445.8188,case rate,
CHILDHOOD BEHAVIORAL DISORDERS,758-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21123.13612,,,21123.13612,4163,30255.56933,case rate,
EATING DISORDERS,759-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16547.8717,,,16547.8717,4163,26874.8916,case rate,
EATING DISORDERS,759-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17552.88506,,,17552.88506,4163,27017.52262,case rate,
EATING DISORDERS,759-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24736.50159,,,24736.50159,4163,43860.6192,case rate,
EATING DISORDERS,759-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42174.40818,,,42174.40818,4163,81708.4556,case rate,
OTHER MENTAL HEALTH DISORDERS,760-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10899.94302,,,10899.94302,4163,12464.52588,case rate,
OTHER MENTAL HEALTH DISORDERS,760-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12859.53248,,,12859.53248,4163,16861.3356,case rate,
OTHER MENTAL HEALTH DISORDERS,760-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16764.76793,,,16764.76793,4163,28750.30229,case rate,
OTHER MENTAL HEALTH DISORDERS,760-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28714.34341,,,28714.34341,4163,36459.00884,case rate,
"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4321.252474,,,4321.252474,2690.585925,6198.868,case rate,
"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5204.586466,,,5204.586466,3943.718588,7857.428,case rate,
"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11854.82006,,,11854.82006,4163,16311.9376,case rate,
"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43554.27021,,,43554.27021,4163,43554.27021,case rate,
ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,772-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12128.73405,,,12128.73405,4163,20526.7532,case rate,
ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,772-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14071.81203,,,14071.81203,4163,20526.7532,case rate,
ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,772-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14682.79691,,,14682.79691,4163,20526.7532,case rate,
ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,772-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50558.74824,,,50558.74824,4163,50558.74824,case rate,
OPIOID ABUSE & DEPENDENCE,773-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4923.690711,,,4923.690711,4163,7596.2048,case rate,
OPIOID ABUSE & DEPENDENCE,773-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6301.225484,,,6301.225484,4163,10334.902,case rate,
OPIOID ABUSE & DEPENDENCE,773-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12550.93034,,,12550.93034,4163,23483.1364,case rate,
OPIOID ABUSE & DEPENDENCE,773-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36938.72476,,,36938.72476,4163,41123.4185,case rate,
COCAINE ABUSE & DEPENDENCE,774-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6416.565081,,,6416.565081,3928.873976,10274.7792,case rate,
COCAINE ABUSE & DEPENDENCE,774-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6720.191706,,,6720.191706,4163,10378.4392,case rate,
COCAINE ABUSE & DEPENDENCE,774-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13367.27548,,,13367.27548,4163,16765.9684,case rate,
COCAINE ABUSE & DEPENDENCE,774-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45820.27499,,,45820.27499,4163,45820.27499,case rate,
ALCOHOL ABUSE & DEPENDENCE,775-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6123.431171,,,6123.431171,4163,9460.0116,case rate,
ALCOHOL ABUSE & DEPENDENCE,775-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9149.906888,,,9149.906888,4163,13477.8732,case rate,
ALCOHOL ABUSE & DEPENDENCE,775-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17622.52217,,,17622.52217,4163,25550.1168,case rate,
ALCOHOL ABUSE & DEPENDENCE,775-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52331.17418,,,52331.17418,4163,81254.9276,case rate,
OTHER DRUG ABUSE & DEPENDENCE,776-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6497.758219,,,6497.758219,4163,10842.836,case rate,
OTHER DRUG ABUSE & DEPENDENCE,776-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8611.869435,,,8611.869435,4163,11475.162,case rate,
OTHER DRUG ABUSE & DEPENDENCE,776-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15007.75003,,,15007.75003,4163,18763.54553,case rate,
OTHER DRUG ABUSE & DEPENDENCE,776-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34820.09947,,,34820.09947,4163,34820.09947,case rate,
O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT,791-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18173.74071,,,18173.74071,17580.736,18173.74071,case rate,
O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT,791-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27112.81027,,,27112.81027,27112.81027,29507.8556,case rate,
O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT,791-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47893.83979,,,47893.83979,47893.83979,55439.4412,case rate,
O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT,791-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,113485.5768,,,113485.5768,113485.5768,137053.0324,case rate,
ACUTE MAJOR EYE INFECTIONS,80-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7669.451235,,,7669.451235,7669.451235,7669.451235,case rate,
ACUTE MAJOR EYE INFECTIONS,80-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11247.96806,,,11247.96806,11247.96806,11247.96806,case rate,
ACUTE MAJOR EYE INFECTIONS,80-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19088.45253,,,19088.45253,19088.45253,19088.45253,case rate,
ACUTE MAJOR EYE INFECTIONS,80-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52142.56615,,,52142.56615,52142.56615,52142.56615,case rate,
ALLERGIC REACTIONS,811-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5676.618131,,,5676.618131,3623.322379,7813.7496,case rate,
ALLERGIC REACTIONS,811-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7911.184894,,,7911.184894,5976.193381,11623.14,case rate,
ALLERGIC REACTIONS,811-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17531.69901,,,17531.69901,10055.98758,22351.4232,case rate,
ALLERGIC REACTIONS,811-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49700.37206,,,49700.37206,22568.75844,49700.37206,case rate,
POISONING OF MEDICINAL AGENTS,812-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6580.195235,,,6580.195235,4079.794198,8626.1196,case rate,
POISONING OF MEDICINAL AGENTS,812-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8277.968424,,,8277.968424,5519.721562,12308.0304,case rate,
POISONING OF MEDICINAL AGENTS,812-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15212.78928,,,15212.78928,7542.299947,19073.44,case rate,
POISONING OF MEDICINAL AGENTS,812-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37989.92211,,,37989.92211,16447.8301,45328.4448,case rate,
OTHER COMPLICATIONS OF TREATMENT,813-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9406.246083,,,9406.246083,5669.404733,13412.8536,case rate,
OTHER COMPLICATIONS OF TREATMENT,813-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12655.4161,,,12655.4161,7962.897287,16522.356,case rate,
OTHER COMPLICATIONS OF TREATMENT,813-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21217.7511,,,21217.7511,12449.68126,23961.1656,case rate,
OTHER COMPLICATIONS OF TREATMENT,813-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49353.14952,,,49353.14952,22671.43368,54185.1552,case rate,
"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",815-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9248.654757,,,9248.654757,4531.317813,9506.833022,case rate,
"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",815-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10119.48978,,,10119.48978,6949.752518,13352.8632,case rate,
"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",815-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17479.47619,,,17479.47619,11911.56408,22497.32659,case rate,
"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",815-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51452.15363,,,51452.15363,21705.29685,60952.7929,case rate,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10822.28089,,,10822.28089,4087.216504,12685.47,case rate,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11903.11062,,,11903.11062,5840.117771,13430.3508,case rate,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16453.47741,,,16453.47741,7023.975578,18266.9652,case rate,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40797.19441,,,40797.19441,15849.09741,43412.808,case rate,
EYE DISORDERS EXCEPT MAJOR INFECTIONS,82-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9417.501173,,,9417.501173,6026.912472,11866.07791,case rate,
EYE DISORDERS EXCEPT MAJOR INFECTIONS,82-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12129.81743,,,12129.81743,7631.367619,15052.29784,case rate,
EYE DISORDERS EXCEPT MAJOR INFECTIONS,82-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16802.14446,,,16802.14446,11573.84916,23193.60803,case rate,
EYE DISORDERS EXCEPT MAJOR INFECTIONS,82-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62488.26118,,,62488.26118,31991.37591,62488.26118,case rate,
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,841-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,88007.0417,,,88007.0417,26814.31748,111264.4976,case rate,
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,841-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89501.92233,,,89501.92233,30521.75932,146821.9508,case rate,
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,841-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,120840.7883,,,120840.7883,109203.1511,303576.6028,case rate,
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,841-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358403.2626,,,358403.2626,225396.8775,410151.8652,case rate,
FULL THICKNESS BURNS W SKIN GRAFT,842-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29103.79762,,,29103.79762,19083.98578,44681.6064,case rate,
FULL THICKNESS BURNS W SKIN GRAFT,842-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42910.12193,,,42910.12193,24716.27898,58762.7808,case rate,
FULL THICKNESS BURNS W SKIN GRAFT,842-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79926.02733,,,79926.02733,42663.41489,93889.83445,case rate,
FULL THICKNESS BURNS W SKIN GRAFT,842-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,197817.4202,,,197817.4202,123239.9688,216388.0481,case rate,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,843-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11056.99266,,,11056.99266,6250.818703,40871.0648,case rate,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,843-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15253.55638,,,15253.55638,7184.792208,40871.0648,case rate,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,843-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27857.05061,,,27857.05061,11055.52479,40871.0648,case rate,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,843-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75152.58505,,,75152.58505,27429.13182,92760.91211,case rate,
PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT,844-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10244.41928,,,10244.41928,3558.995727,13461.2876,case rate,
PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT,844-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16760.37423,,,16760.37423,7095.724536,22050.5552,case rate,
PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT,844-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29521.05852,,,29521.05852,13734.97725,39019.6972,case rate,
PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT,844-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,119309.2333,,,119309.2333,37509.86042,119309.2333,case rate,
"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",850-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26651.39169,,,26651.39169,16233.82027,40893.456,case rate,
"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",850-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30216.48668,,,30216.48668,26437.01692,55463.6244,case rate,
"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",850-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,57264.7156,,,57264.7156,33009.46888,67991.6196,case rate,
"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",850-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,121786.2961,,,121786.2961,65129.4981,158116.7444,case rate,
REHABILITATION,860-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15236.40291,,,15236.40291,14210.00484,31767.6436,case rate,
REHABILITATION,860-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21014.77829,,,21014.77829,17966.92872,37191.1348,case rate,
REHABILITATION,860-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31144.11878,,,31144.11878,20564.73582,49180.4504,case rate,
REHABILITATION,860-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44282.58088,,,44282.58088,22327.5335,49180.4504,case rate,
"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",861-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7653.962947,,,7653.962947,5162.213823,10782.22233,case rate,
"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",861-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10339.05432,,,10339.05432,6654.097329,14677.6512,case rate,
"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",861-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15477.39425,,,15477.39425,10072.06924,21930.3096,case rate,
"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",861-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35599.56965,,,35599.56965,20888.84319,43334.0264,case rate,
OTHER AFTERCARE & CONVALESCENCE,862-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7142.668873,,,7142.668873,4630.281893,12895.85337,case rate,
OTHER AFTERCARE & CONVALESCENCE,862-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12527.71797,,,12527.71797,6746.876154,17745.03675,case rate,
OTHER AFTERCARE & CONVALESCENCE,862-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19669.34359,,,19669.34359,7539.825845,26528.54827,case rate,
OTHER AFTERCARE & CONVALESCENCE,862-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35179.54011,,,35179.54011,7915.889349,44418.31,case rate,
NEONATAL AFTERCARE,863-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15421.15892,,,15421.15892,12751.52171,21059.13,case rate,
NEONATAL AFTERCARE,863-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43591.20536,,,43591.20536,18800.7011,53571.4272,case rate,
NEONATAL AFTERCARE,863-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78036.81729,,,78036.81729,43645.63338,104410.7916,case rate,
NEONATAL AFTERCARE,863-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,186439.3666,,,186439.3666,109858.868,225297.7466,case rate,
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,890-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21700.19523,,,21700.19523,10628.74219,23085.082,case rate,
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,890-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25146.31929,,,25146.31929,11189.1263,25146.31929,case rate,
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,890-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35815.3223,,,35815.3223,16691.52914,39929.832,case rate,
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,890-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80427.67131,,,80427.67131,31893.64888,80427.67131,case rate,
MAJOR CRANIAL/FACIAL BONE PROCEDURES,89-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29447.18822,,,29447.18822,15622.71708,36434.22212,case rate,
MAJOR CRANIAL/FACIAL BONE PROCEDURES,89-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38745.09653,,,38745.09653,27834.88455,48165.09975,case rate,
HIV W MAJOR HIV RELATED CONDITION,892-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12938.41842,,,12938.41842,8930.271169,16769.8164,case rate,
HIV W MAJOR HIV RELATED CONDITION,892-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18339.05612,,,18339.05612,9432.513875,19345.0292,case rate,
HIV W MAJOR HIV RELATED CONDITION,892-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24817.61448,,,24817.61448,12723.06954,27148.554,case rate,
HIV W MAJOR HIV RELATED CONDITION,892-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48052.71512,,,48052.71512,24712.56783,48398.854,case rate,
MAJOR CRANIAL/FACIAL BONE PROCEDURES,89-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69570.04021,,,69570.04021,45277.30365,80847.5141,case rate,
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17568.27303,,,17568.27303,10636.1645,18472.044,case rate,
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18809.98435,,,18809.98435,11138.4072,20009.298,case rate,
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28900.70443,,,28900.70443,13720.13264,30111.1568,case rate,
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50292.65865,,,50292.65865,28810.91779,50292.65865,case rate,
MAJOR CRANIAL/FACIAL BONE PROCEDURES,89-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,135133.2683,,,135133.2683,73853.18175,138501.4202,case rate,
HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,894-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11760.50602,,,11760.50602,6723.372185,13617.8208,case rate,
HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,894-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14461.14587,,,14461.14587,8786.773253,17042.2728,case rate,
HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,894-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20782.45396,,,20782.45396,13374.99541,24656.0544,case rate,
HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,894-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41338.26131,,,41338.26131,24032.5344,41338.26131,case rate,
MAJOR LARYNX & TRACHEA PROCEDURES,90-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13630.15507,,,13630.15507,13630.15507,13630.15507,case rate,
MAJOR LARYNX & TRACHEA PROCEDURES,90-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45805.46883,,,45805.46883,45805.46883,45805.46883,case rate,
MAJOR LARYNX & TRACHEA PROCEDURES,90-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72769.27454,,,72769.27454,72769.27454,72769.27454,case rate,
MAJOR LARYNX & TRACHEA PROCEDURES,90-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,144932.5999,,,144932.5999,144932.5999,144932.5999,case rate,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58900.37514,,,58900.37514,41677.48524,77939.8808,case rate,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65295.51342,,,65295.51342,47677.18259,85066.3872,case rate,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,92318.66415,,,92318.66415,53675.64289,95769.6744,case rate,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189232.1738,,,189232.1738,90084.52792,189232.1738,case rate,
OTHER MAJOR HEAD & NECK PROCEDURES,91-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27449.07866,,,27449.07866,14823.58213,29640.40805,case rate,
EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,911-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26156.06741,,,26156.06741,26156.06741,40947.65814,case rate,
EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,911-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41135.79006,,,41135.79006,30735.76915,52459.1052,case rate,
EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,911-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59554.4945,,,59554.4945,31043.79485,71461.0644,case rate,
EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,911-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,158230.479,,,158230.479,67139.70597,158230.479,case rate,
OTHER MAJOR HEAD & NECK PROCEDURES,91-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41541.11374,,,41541.11374,25589.63699,45965.84186,case rate,
MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41332.86448,,,41332.86448,27601.08191,51666.732,case rate,
MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45925.72375,,,45925.72375,27690.14958,52399.1148,case rate,
MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77245.99171,,,77245.99171,31402.53964,83091.7032,case rate,
MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,154215.8425,,,154215.8425,62592.3065,157078.0712,case rate,
OTHER MAJOR HEAD & NECK PROCEDURES,91-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77244.30646,,,77244.30646,51338.85355,80313.473,case rate,
OTHER MAJOR HEAD & NECK PROCEDURES,91-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,125726.5407,,,125726.5407,112767.0951,143844.0846,case rate,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES,92-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20930.05414,,,20930.05414,16195.47169,27186.52297,case rate,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES,92-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29289.07526,,,29289.07526,24432.9943,36580.68909,case rate,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES,92-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50147.94748,,,50147.94748,29467.79187,59995.12425,case rate,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES,92-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,109717.7898,,,109717.7898,83676.60374,120508.5162,case rate,
MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE,930-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16691.80043,,,16691.80043,8180.618263,18694.5084,case rate,
MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE,930-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20587.78705,,,20587.78705,9733.117268,22506.3984,case rate,
MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE,930-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33201.67367,,,33201.67367,14993.05812,35419.332,case rate,
MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE,930-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,88840.39988,,,88840.39988,30959.67538,88840.39988,case rate,
SINUS & MASTOID PROCEDURES,93-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20642.35718,,,20642.35718,20642.35718,20642.35718,case rate,
SINUS & MASTOID PROCEDURES,93-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27301.81955,,,27301.81955,27301.81955,27301.81955,case rate,
SINUS & MASTOID PROCEDURES,93-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41976.77201,,,41976.77201,41976.77201,41976.77201,case rate,
SINUS & MASTOID PROCEDURES,93-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62534.60567,,,62534.60567,62534.60567,62534.60567,case rate,
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28505.55246,,,28505.55246,14584.83129,35254.3584,case rate,
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43003.59335,,,43003.59335,20831.93884,47919.8316,case rate,
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,68188.23211,,,68188.23211,33165.33731,82811.9008,case rate,
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,136897.2278,,,136897.2278,71562.1633,168225.6676,case rate,
CLEFT LIP & PALATE REPAIR,95-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11973.85117,,,11973.85117,11973.85117,17041.99529,case rate,
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20193.59807,,,20193.59807,11862.08204,26835.7056,case rate,
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29978.64515,,,29978.64515,15976.51367,36514.1568,case rate,
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50729.64104,,,50729.64104,26771.02069,56221.0376,case rate,
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,105118.651,,,105118.651,52603.11967,130095.3732,case rate,
CLEFT LIP & PALATE REPAIR,95-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14362.25756,,,14362.25756,14362.25756,19308.85332,case rate,
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15496.77467,,,15496.77467,9786.310461,21918.9924,case rate,
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23715.41814,,,23715.41814,13476.43359,30187.6692,case rate,
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41961.80534,,,41961.80534,25246.97386,50666.9348,case rate,
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89974.67624,,,89974.67624,49125.76931,122973.9312,case rate,
CLEFT LIP & PALATE REPAIR,95-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24552.56814,,,24552.56814,24436.70545,31037.47761,case rate,
CLEFT LIP & PALATE REPAIR,95-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51750.86493,,,51750.86493,36149.10432,69531.25067,case rate,
TONSIL & ADENOID PROCEDURES,97-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7670.133362,,,7670.133362,7292.415645,12192.81192,case rate,
TONSIL & ADENOID PROCEDURES,97-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12826.00796,,,12826.00796,8903.056047,17609.83647,case rate,
TONSIL & ADENOID PROCEDURES,97-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28329.1224,,,28329.1224,19357.37405,30780.59708,case rate,
TONSIL & ADENOID PROCEDURES,97-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81191.09145,,,81191.09145,45078.13844,81191.09145,case rate,
"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",98-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14806.34209,,,14806.34209,9798.680971,20198.92183,case rate,
"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",98-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20253.72553,,,20253.72553,14894.09404,27970.68459,case rate,
"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",98-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34496.55074,,,34496.55074,26093.11674,48198.89982,case rate,
"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",98-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77028.2328,,,77028.2328,50136.43998,90331.81374,case rate,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.7355,1592,other,SI=N Exclusions 
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1338.33,,,1268.58,399.86,2141,fee schedule,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,57.921,1592,other,SI=N Exclusions 
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,283.26,,,268.5,195.5395,1592,fee schedule,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,155.354,2141,fee schedule,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1110.33,,,1052.46,291.227805,2141,fee schedule,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.185,1592,other,SI=N Exclusions 
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,206.989,1592,fee schedule,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,206.989,1592,fee schedule,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1676.16,,,1588.8,399.86,3715.584,fee schedule,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,205.642,1592,fee schedule,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,205.642,1592,fee schedule,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3047.3,,,2888.48,399.86,6635.52,fee schedule,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.31,,,459.07,263.563,1592,fee schedule,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.8985,1592,other,SI=N Exclusions 
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,815.8252,399.86,2998,percent of total billed charges,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,801.8007,399.86,2998,percent of total billed charges,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,727.2705,399.86,2998,percent of total billed charges,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,282.8942,158.497,3914,percent of total billed charges,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,2141,fee schedule,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,2141,fee schedule,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,6928.896,fee schedule,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.31,,,459.07,228.541,1592,fee schedule,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.31,,,459.07,239.0925,1592,fee schedule,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2477.315575,fee schedule,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.0735,1592,other,SI=N Exclusions 
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.0735,1592,other,SI=N Exclusions 
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1592,other,SI=N Exclusions 
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65.61,,,62.19,62.19,1592,fee schedule,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,66.75974,1592,fee schedule,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,47.594,1592,fee schedule,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,96.7595,1592,fee schedule,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.2055,1592,other,SI=N Exclusions 
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65.61,,,62.19,35.6955,1592,fee schedule,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,1592,fee schedule,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,2141,fee schedule,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,113.876282,1592,fee schedule,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,156.65,1592,fee schedule,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,113.3725,1592,fee schedule,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,113.3725,1592,fee schedule,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,99.9025,1592,fee schedule,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,115.1685,1592,fee schedule,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,145.476,1592,fee schedule,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,95.4125,1592,fee schedule,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,73.8605,1592,fee schedule,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,89.8,1592,fee schedule,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,107.5355,1592,fee schedule,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,142.1085,1592,fee schedule,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,174.8855,1592,fee schedule,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,124.5975,1592,fee schedule,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,100.576,1592,fee schedule,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,309.1365,1592,fee schedule,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,181.6205,1592,fee schedule,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,200.0295,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,113.3725,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,153.7825,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,153.7825,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,145.7005,1592,fee schedule,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,399.86,3459.072,fee schedule,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,142.333,1592,fee schedule,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,142.1085,1592,fee schedule,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,139.8635,1592,fee schedule,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,140.7615,1592,fee schedule,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,237.072,2141,fee schedule,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,399.86,4022.784,fee schedule,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,200.0295,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,133.802,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,148.8435,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,146.374,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,168.1505,1592,fee schedule,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,318.5655,1592,fee schedule,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,254.134,1592,fee schedule,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,399.86,1592,fee schedule,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,244.705,1592,fee schedule,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,56.125,1592,other,SI=N Exclusions 
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,395.3445,1592,fee schedule,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,165.0075,1592,fee schedule,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,68.4725,1592,other,SI=N Exclusions 
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,257.0525,1592,fee schedule,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,162.3135,1592,fee schedule,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.761,1592,other,SI=N Exclusions 
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,395.3445,1592,fee schedule,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,166.8035,1592,fee schedule,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,103.719,1592,other,SI=N Exclusions 
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3488.41,,,3306.6,399.86,3459.072,fee schedule,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,1592,fee schedule,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,4341.777195,fee schedule,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,5804.544,fee schedule,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3488.41,,,3306.6,399.86,7323.648,fee schedule,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2567.93,,,2434.09,399.86,4478.208,fee schedule,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,5804.544,fee schedule,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3488.41,,,3306.6,399.86,5481.863562,fee schedule,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3488.41,,,3306.6,399.86,7323.648,fee schedule,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,5804.544,fee schedule,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,88.2285,1592,fee schedule,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,182.294,1592,fee schedule,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,182.294,1592,fee schedule,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,189.7025,1592,fee schedule,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,268.469,150.415,2998,percent of total billed charges,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.31,,,459.07,395.7935,1592,fee schedule,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,798.19,,,756.59,367.5065,2141,fee schedule,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.47,1592,other,Non-Reimbursable List
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,3315.456,fee schedule,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3070.464,other,Non-Reimbursable List
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,2998,fee schedule,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1794.048,other,Non-Reimbursable List
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,3932.16,fee schedule,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1714.176,other,Non-Reimbursable List
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,2998,fee schedule,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,197.56,1592,other,Non-Reimbursable List
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,2141,fee schedule,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.858,1592,other,Non-Reimbursable List
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,2141,fee schedule,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,61.513,1592,other,Non-Reimbursable List
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,2141,fee schedule,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10538.68,,,9989.41,399.86,14403.82399,fee schedule,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,2998,fee schedule,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,6928.896,fee schedule,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,2998,fee schedule,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2954.496,fee schedule,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,2998,fee schedule,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,6928.896,fee schedule,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,6928.896,fee schedule,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,4007.424,fee schedule,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,4449.024,fee schedule,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,184.7635,1592,fee schedule,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,202.7235,1592,fee schedule,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,147.721,1592,fee schedule,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,160.293,1592,fee schedule,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,160.293,1592,fee schedule,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,628.09,,,595.36,210.581,1592,fee schedule,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,169.0485,1592,fee schedule,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,169.0485,1592,fee schedule,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1488.49,,,1410.91,399.86,2141,fee schedule,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,147.721,1592,fee schedule,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,147.721,1592,fee schedule,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,628.09,,,595.36,176.008,1592,fee schedule,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7941.18,,,7527.29,399.86,20110.10933,fee schedule,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,3683.328,fee schedule,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,380.5275,1592,other,Non-Reimbursable List
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2477.315575,fee schedule,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.74,,,292.65,165.0075,1592,fee schedule,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2400.36,,,2275.25,399.86,2998,fee schedule,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3047.3,,,2888.48,399.86,4341.777195,fee schedule,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1676.16,,,1588.8,399.86,2998,fee schedule,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,4007.424,fee schedule,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,6928.896,fee schedule,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,274.788,1592,other,Non-Reimbursable List
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3592.92,,,3405.66,399.86,7643.136,fee schedule,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3592.92,,,3405.66,399.86,3826.944,fee schedule,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3592.92,,,3405.66,399.86,16604.928,fee schedule,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5328.87,,,5051.13,399.86,7643.136,fee schedule,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,4007.424,fee schedule,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,6928.896,fee schedule,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,921.41,,,873.38,399.86,2455.793921,fee schedule,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1676.16,,,1588.8,399.86,2998,fee schedule,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,7643.136,fee schedule,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,7643.136,fee schedule,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,7643.136,fee schedule,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,3826.944,fee schedule,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,3826.944,fee schedule,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,7643.136,fee schedule,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,3826.944,fee schedule,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2841.6,fee schedule,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2841.6,fee schedule,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1402.0493,399.86,2998,percent of total billed charges,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.74,,,292.65,202.499,1592,fee schedule,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2400.36,,,2275.25,399.86,2455.793921,fee schedule,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.74,,,292.65,150.6395,1592,fee schedule,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2400.36,,,2275.25,399.86,2998,fee schedule,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,478.21,,,453.29,160.5175,1592,fee schedule,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3047.3,,,2888.48,399.86,5885.184,fee schedule,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,324.627,1592,other,Non-Reimbursable List
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,187.233,1592,other,Non-Reimbursable List
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.74,,,292.65,292.65,2813.184,fee schedule,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,436.93,,,414.16,149.068,1592,fee schedule,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,436.93,,,414.16,200.4785,1592,fee schedule,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,110.2295,1592,fee schedule,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,114.7195,1592,fee schedule,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,101.6985,1592,fee schedule,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,79.473,1592,fee schedule,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,79.473,1592,fee schedule,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,49.6145,1592,fee schedule,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,48.941,1592,fee schedule,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,90.9225,1592,fee schedule,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,27.389,1592,fee schedule,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,27.389,1592,fee schedule,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,436.93,,,414.16,156.9255,1592,fee schedule,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,124.373,1592,fee schedule,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,79.473,1592,fee schedule,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,77.9015,1592,fee schedule,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,77.9015,1592,fee schedule,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,64.8805,1592,fee schedule,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,64.8805,1592,fee schedule,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,109.107,1592,fee schedule,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,114.495,1592,fee schedule,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,371.53,,,352.17,122.128,1592,fee schedule,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,371.53,,,352.17,122.128,1592,fee schedule,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,371.53,,,352.17,122.128,1592,fee schedule,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,233.18,,,221.03,138.0675,1592,fee schedule,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,330.07,,,312.86,83.2895,1592,fee schedule,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1764.64,,,1672.67,399.86,2998,fee schedule,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1764.64,,,1672.67,399.86,2998,fee schedule,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1764.64,,,1672.67,399.86,3022.08,fee schedule,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1764.64,,,1672.67,399.86,2998,fee schedule,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3250.31,,,3080.91,399.86,3528.192,fee schedule,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5218.7,,,4946.71,399.86,6425.856,fee schedule,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2141,fee schedule,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2274.27,,,2155.74,399.86,3224.064,fee schedule,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2141,fee schedule,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,367.282,2141,fee schedule,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,367.282,2141,fee schedule,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2998,fee schedule,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,1739.52,fee schedule,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,319.0145,2141,fee schedule,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,319.0145,2141,fee schedule,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3437.08,,,3257.95,399.86,4252.416,fee schedule,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3437.08,,,3257.95,399.86,4252.416,fee schedule,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12358.09,,,11714,399.86,21000.192,fee schedule,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12358.09,,,11714,399.86,28237.056,fee schedule,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15295.82,,,14498.62,399.86,21000.192,fee schedule,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8699.95,,,8246.52,399.86,16478.208,fee schedule,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9928.88,,,9411.4,399.86,16478.208,fee schedule,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11584.14,,,10980.38,399.86,21000.192,fee schedule,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15295.82,,,14498.62,399.86,21000.192,fee schedule,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,4870.452937,fee schedule,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8699.95,,,8246.52,399.86,16478.208,fee schedule,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11584.14,,,10980.38,399.86,37615.872,fee schedule,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2567.93,,,2434.09,399.86,3459.072,fee schedule,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2567.93,,,2434.09,399.86,2998,fee schedule,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15295.82,,,14498.62,399.86,21000.192,fee schedule,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6364,other,Non-Reimbursable List
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,4870.452937,fee schedule,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9928.88,,,9411.4,399.86,13659.648,fee schedule,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11584.14,,,10980.38,399.86,16316.30039,fee schedule,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11584.14,,,10980.38,399.86,29773.2518,fee schedule,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,51836.928,fee schedule,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,50269.54813,fee schedule,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,16478.208,fee schedule,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6933.504,fee schedule,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46068.04,,,43667.02,399.86,66342.912,fee schedule,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,48388.608,fee schedule,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,50497.536,fee schedule,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,50497.536,fee schedule,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11110.6096,399.86,21295.104,percent of total billed charges,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11110.6096,399.86,21295.104,percent of total billed charges,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,22573.824,percent of total billed charges,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,22573.824,percent of total billed charges,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11110.6096,399.86,23502.2528,percent of total billed charges,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,24913.5068,percent of total billed charges,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,24913.5068,percent of total billed charges,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2785.2657,399.86,5338.368,percent of total billed charges,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2392.179,399.86,4584.96,percent of total billed charges,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1771.094,399.86,3746.392,percent of total billed charges,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,660.7543,370.2005,2998,percent of total billed charges,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1530.674,399.86,3237.832,percent of total billed charges,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1680.5358,399.86,3220.992,percent of total billed charges,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,721.26,399.86,2998,percent of total billed charges,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1006.9591,399.86,6913,percent of total billed charges,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,55.6973,31.2055,6913,percent of total billed charges,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1646.4763,399.86,3155.712,percent of total billed charges,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1678.1316,399.86,3549.7488,percent of total billed charges,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1678.1316,399.86,3549.7488,percent of total billed charges,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1646.4763,399.86,3155.712,percent of total billed charges,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1678.1316,293.5896,3216.384,percent of total billed charges,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1336.39,,,1266.74,397.365,2141,fee schedule,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1336.39,,,1266.74,397.365,2141,fee schedule,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,60.9064,34.124,2998,percent of total billed charges,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,95.3666,53.431,2998,percent of total billed charges,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,66.9169,37.4915,2998,percent of total billed charges,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,135.0359,75.6565,2998,percent of total billed charges,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,179.1129,100.3515,2998,percent of total billed charges,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,87.3526,48.941,2998,percent of total billed charges,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,77.0035,1592,other,Non-Reimbursable List
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,173.9875,2141,fee schedule,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,57.921,1592,other,Non-Reimbursable List
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,121.4545,1592,other,Non-Reimbursable List
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,173.5385,1592,other,Non-Reimbursable List
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,204.0705,1592,other,Non-Reimbursable List
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6398.208,other,Non-Reimbursable List
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,161.8645,1592,other,Non-Reimbursable List
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,373.119,1592,other,Non-Reimbursable List
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,140.986,1592,other,Non-Reimbursable List
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,76.33,1592,other,Non-Reimbursable List
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2003.712,other,Non-Reimbursable List
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,161.8645,1592,other,Non-Reimbursable List
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.235,1592,other,Non-Reimbursable List
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.516,1592,other,Non-Reimbursable List
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,346.8525,1592,other,Non-Reimbursable List
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.4705,1592,other,Non-Reimbursable List
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7442.688,fee schedule,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7442.688,fee schedule,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,8396.844904,fee schedule,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8386.59,,,7949.49,399.86,12170.496,fee schedule,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7020.288,fee schedule,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8386.59,,,7949.49,399.86,12170.496,fee schedule,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,115.6175,1592,other,Non-Reimbursable List
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.394,1592,other,Non-Reimbursable List
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.5215,1592,other,Non-Reimbursable List
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,277.482,1592,other,Non-Reimbursable List
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,323.729,1592,other,Non-Reimbursable List
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,57.921,1592,other,Non-Reimbursable List
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7242.24,fee schedule,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7242.24,fee schedule,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,8396.844904,fee schedule,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7242.24,fee schedule,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.388,416.02,other,Non-Reimbursable List
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,601.64,,,570.29,207.2135,1592,fee schedule,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,156.65,1592,fee schedule,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,204.0705,1592,fee schedule,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,85.9835,1592,fee schedule,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6987.24,,,6623.08,399.86,6623.08,fee schedule,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1592,other,Non-Reimbursable List
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4524.72,,,4288.9,399.86,5781.504,fee schedule,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1592,other,Non-Reimbursable List
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,205.4175,1592,other,Non-Reimbursable List
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,92.494,1592,other,Non-Reimbursable List
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,173.5385,1592,other,Non-Reimbursable List
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2196.1,,,2081.64,300.1565,2081.64,fee schedule,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2196.1,,,2081.64,399.86,3777.792,fee schedule,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,5781.504,fee schedule,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,5781.504,fee schedule,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,6012.672,fee schedule,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,6012.672,fee schedule,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,6012.672,fee schedule,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,9631.488,fee schedule,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,9631.488,fee schedule,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2953.728,fee schedule,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2953.728,fee schedule,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,319.0145,2141,fee schedule,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,319.0145,2141,fee schedule,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2998,fee schedule,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,35.92,1592,other,Non-Reimbursable List
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,28.0625,1592,other,Non-Reimbursable List
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.86,,,378.07,180.947,1592,fee schedule,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.86,,,378.07,91.147,1592,fee schedule,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,66.6765,1592,other,Non-Reimbursable List
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,69.3705,1592,other,Non-Reimbursable List
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,4288.2914,399.86,9071.0152,percent of total billed charges,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,283.26,,,268.5,127.516,1592,fee schedule,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,283.26,,,268.5,127.516,1592,fee schedule,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6190.44,,,5867.8,399.86,9631.488,fee schedule,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1650.884,399.86,5756,percent of total billed charges,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,18955.84,fee schedule,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,26793.51305,fee schedule,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,184.988,4800.911611,other,Non-Reimbursable List
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,277.482,8164.18419,other,Non-Reimbursable List
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,20286.72,fee schedule,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,6788.57,fee schedule,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6987.24,,,6623.08,399.86,10775.04,fee schedule,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,7394.304,fee schedule,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,7678.464,fee schedule,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.86,,,378.07,137.6185,1592,fee schedule,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,6777.6,fee schedule,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,9631.488,fee schedule,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,4870.452937,fee schedule,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5548.032,fee schedule,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5548.032,fee schedule,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,221.5871,124.1485,2998,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,12283.392,fee schedule,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,18955.84,fee schedule,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12148.224,other,Non-Reimbursable List
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12453.888,other,Non-Reimbursable List
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,12748.032,fee schedule,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,26793.51305,fee schedule,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,25020.672,fee schedule,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33718.77,,,31961.39,399.86,45315.84,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,16809.6787,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,26793.51305,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,26793.51305,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33718.77,,,31961.39,399.86,44656.128,fee schedule,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12327.936,other,Non-Reimbursable List
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,25786.368,other,Non-Reimbursable List
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12327.936,other,Non-Reimbursable List
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12148.224,other,Non-Reimbursable List
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,20286.72,fee schedule,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4532,other,Non-Reimbursable List
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,20286.72,fee schedule,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4532,other,Non-Reimbursable List
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,26793.51305,fee schedule,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,3565.824,fee schedule,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4524.72,,,4288.9,399.86,5781.504,fee schedule,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4524.72,,,4288.9,399.86,5781.504,fee schedule,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,85.5345,1592,other,SI=N Exclusions 
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,624.65,,,592.09,399.86,2477.315575,fee schedule,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,624.65,,,592.09,399.86,2477.315575,fee schedule,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,624.65,,,592.09,399.86,2477.315575,fee schedule,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,624.65,,,592.09,399.86,2477.315575,fee schedule,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3114.08,,,2951.78,399.86,4341.777195,fee schedule,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3114.08,,,2951.78,399.86,4341.777195,fee schedule,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,2998,fee schedule,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.25,1592,other,SI=N Exclusions 
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,216.378,121.23,1592,percent of total billed charges,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,2477.315575,fee schedule,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,367.5065,2141,fee schedule,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,95.188,1592,other,Non-Reimbursable List
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,530.88,,,503.21,119.6585,1592,fee schedule,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,530.88,,,503.21,153.7825,1592,fee schedule,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,263.95,,,250.2,72.9625,1592,fee schedule,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,263.95,,,250.2,72.9625,1592,fee schedule,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.9855,1592,other,Non-Reimbursable List
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1440.23,,,1365.17,111.352,1592,fee schedule,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,496.37,,,470.5,197.3355,1592,fee schedule,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,496.37,,,470.5,197.3355,1592,fee schedule,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,375.5885,2998,fee schedule,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4226.17,,,4005.9,399.86,4005.9,fee schedule,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2954.27,,,2800.3,399.86,4934.4,fee schedule,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2954.27,,,2800.3,399.86,2998,fee schedule,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,218.214,1592,other,Non-Reimbursable List
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9348.07,,,8860.86,399.86,10219.776,fee schedule,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4684.33,,,4440.19,399.86,6425.856,fee schedule,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4684.33,,,4440.19,399.86,6425.856,fee schedule,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9348.07,,,8860.86,399.86,15728.70471,fee schedule,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,697.218,390.63,2998,percent of total billed charges,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3431.5948,399.86,6577.152,percent of total billed charges,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3431.5948,399.86,6577.152,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,207.6625,2998,fee schedule,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,367.0575,2998,fee schedule,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,367.0575,2998,fee schedule,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4279.65,,,4056.59,399.86,6425.856,fee schedule,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2583.94,,,2449.27,399.86,2998,fee schedule,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2583.94,,,2449.27,399.86,2998,fee schedule,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5218.7,,,4946.71,399.86,6116.352,fee schedule,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,5781.504,fee schedule,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2775.82,,,2631.14,399.86,3280.128,fee schedule,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.2295,1592,other,Non-Reimbursable List
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2140.95,,,2029.37,399.86,3280.128,fee schedule,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2140.95,,,2029.37,399.86,3280.128,fee schedule,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,369.078,2998,fee schedule,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,369.078,2998,fee schedule,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,379.854,2998,fee schedule,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,379.854,2998,fee schedule,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,399.86,2998,fee schedule,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,399.86,2998,fee schedule,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,399.86,2998,fee schedule,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,242.8242,136.047,1592,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2.071619,1.160665,416.02,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,20.151203,1.160665,416.02,percent of total billed charges,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,4179.83,fee schedule,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2613.35,,,2477.14,399.86,3616.512,fee schedule,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2775.82,,,2631.14,399.86,3616.512,fee schedule,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1177.6,,,1116.22,339.6685,2141,fee schedule,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,162.987,2141,fee schedule,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,119.6585,1592,fee schedule,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,334.48,2141,fee schedule,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3479.98,,,3298.61,399.86,4225.536,fee schedule,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,8911.104,fee schedule,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9348.07,,,8860.86,399.86,10219.776,fee schedule,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,83.963,1592,other,Non-Reimbursable List
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2775.82,,,2631.14,399.86,3616.512,fee schedule,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,119.6585,1592,other,Non-Reimbursable List
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,8911.104,fee schedule,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,8911.104,fee schedule,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,156.9255,1592,fee schedule,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,156.9255,1592,fee schedule,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,179.53,2998,fee schedule,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,179.53,2998,fee schedule,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3256.18,,,3086.47,399.86,3616.512,fee schedule,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3256.18,,,3086.47,399.86,3616.512,fee schedule,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,219.112,1592,other,Non-Reimbursable List
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,197.3355,1592,fee schedule,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,87.3305,1592,fee schedule,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,87.7795,1592,fee schedule,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,79.473,1592,fee schedule,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,102.372,1592,fee schedule,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,106.6375,1592,fee schedule,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,47.594,1592,fee schedule,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,6210.048,fee schedule,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3919.87,,,3715.57,399.86,5068.032,fee schedule,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,120.28264,1592,fee schedule,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2234.37,,,2117.92,399.86,3616.512,fee schedule,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,273.89,,,259.61,186.1105,1592,fee schedule,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3360.16,,,3185.03,399.86,4777.053449,fee schedule,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3360.16,,,3185.03,399.86,5299.2,fee schedule,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,273.89,,,259.61,110.005,416.02,fee schedule,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3360.16,,,3185.03,399.86,4777.053449,fee schedule,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3360.16,,,3185.03,399.86,5511.168,fee schedule,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,798.19,,,756.59,339.893,2141,fee schedule,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12040.59,,,11413.04,399.86,11413.04,fee schedule,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,399.86,2141,fee schedule,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,213.5731,119.6585,5756,percent of total billed charges,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,798.19,,,756.59,367.5065,2141,fee schedule,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,205.4175,2141,fee schedule,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,205.4175,2141,fee schedule,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,205.4175,2141,fee schedule,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,281.972,2141,fee schedule,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,281.972,2141,fee schedule,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,205.4175,2141,fee schedule,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,294.544,1592,other,Non-Reimbursable List
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5732.7,,,5433.92,399.86,6224.0876,fee schedule,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,281.972,1592,other,Non-Reimbursable List
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.5215,1592,other,Non-Reimbursable List
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1171.66,,,1110.59,399.86,2141,fee schedule,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,442.8,,,419.72,155.844464,1592,fee schedule,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,200.0295,1592,fee schedule,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,323.2601,1592,fee schedule,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,196.8865,1592,fee schedule,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,310.259,2141,fee schedule,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,4677.12,fee schedule,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,366.833,2141,fee schedule,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,185.2125,1592,fee schedule,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.635,1592,other,Non-Reimbursable List
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,93.392,1592,other,Non-Reimbursable List
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,49.6145,1592,other,SI=N Exclusions 
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,50.288,1592,other,SI=N Exclusions 
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,380.0785,1592,other,SI=N Exclusions 
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.123,1592,other,SI=N Exclusions 
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,628.09,,,595.36,154.2315,1592,fee schedule,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,628.09,,,595.36,154.2315,1592,fee schedule,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,46.0225,1592,other,Non-Reimbursable List
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,66.75974,1592,other,Non-Reimbursable List
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,60.8395,416.02,fee schedule,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,456.96,fee schedule,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,86.208,416.02,fee schedule,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,66.2275,416.02,fee schedule,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,56.574,416.02,fee schedule,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,73.636,416.02,fee schedule,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,71.24,416.02,fee schedule,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,58.819,416.02,fee schedule,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,76.026473,416.02,fee schedule,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74.47,,,74.47,54.1045,416.02,fee schedule,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,54.1045,416.02,fee schedule,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,549.888,fee schedule,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,360.21,,,360.21,267.439885,1987.584,fee schedule,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74.47,,,74.47,54.1045,416.02,fee schedule,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.084,416.02,fee schedule,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,58.819,416.02,fee schedule,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,120.5565,646.6965,other,Non-Reimbursable List
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,154.41,,,154.41,89.81,821.76,fee schedule,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,201.75,,,201.75,124.33,1023.744,fee schedule,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,195.57,,,195.57,153.75,1240.32,fee schedule,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,267.19,,,267.19,96.160741,575,fee schedule,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,316.17,,,316.17,173.763,667.43,fee schedule,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,355.27,,,355.27,200.53123,1243.392,fee schedule,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,214.92,,,214.92,96.160741,921.6,fee schedule,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,263.48,,,263.48,200.53123,1014.528,fee schedule,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,325.64,,,325.64,200.53123,889.344,fee schedule,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,199.27,,,199.27,96.160741,575,fee schedule,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,249.9,,,249.9,194.55,1138.176,fee schedule,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,310.41,,,310.41,200.53123,1347.84,fee schedule,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,517.04,,,517.04,200.53123,1021.44,fee schedule,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,537.62,,,537.62,200.53123,888.576,fee schedule,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,425.25,,,425.25,237.688956,3902.208,fee schedule,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,472.58,,,472.58,365.99,2081.28,fee schedule,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,571.78,,,571.78,379.854,1299.456,fee schedule,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,498.1,,,498.1,267.439885,1750.272,fee schedule,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,489.05,,,489.05,374.62,1750.272,fee schedule,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,753.3,,,753.3,301.425681,1750.272,fee schedule,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,498.51,,,498.51,267.439885,1675.776,fee schedule,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,531.44,,,531.44,399.86,1896.192,fee schedule,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,755.35,,,755.35,301.425681,1946.112,fee schedule,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,445.83,,,445.83,188.66,1605.12,fee schedule,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,490.28,,,490.28,268.7,4035.84,fee schedule,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,558.2,,,558.2,307.14,2049.024,fee schedule,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.93,,,128.93,48.043,416.02,fee schedule,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.93,,,128.93,52.084,416.02,fee schedule,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.93,,,128.93,55.0025,416.02,fee schedule,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,237.56,,,237.56,76.026473,416.02,fee schedule,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,431.616,fee schedule,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,56.125,416.02,fee schedule,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,200.09,,,200.09,96.160741,1065.984,fee schedule,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,251.54,,,251.54,195.34,1247.232,fee schedule,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,312.88,,,312.88,200.53123,1522.176,fee schedule,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,167.91,,,167.91,59.268,575,fee schedule,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,386.97,,,386.97,200.53123,1222.656,fee schedule,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,496.45,,,496.45,237.688956,1519.872,fee schedule,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,544.61,,,544.61,399.86,2402.304,fee schedule,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.74,,,690.74,347.3015,1288.93,fee schedule,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,466.82,,,466.82,301.425681,1817.856,fee schedule,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,466.82,,,466.82,301.425681,1817.856,fee schedule,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,466.82,,,466.82,301.425681,1817.856,fee schedule,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,56.3495,416.02,fee schedule,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,66.452,416.02,fee schedule,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,67.35,416.02,fee schedule,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,67.35,416.02,fee schedule,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,56.574,416.02,fee schedule,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,63.5335,416.02,fee schedule,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,68.697,416.02,fee schedule,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126.19,,,126.19,54.1045,416.02,fee schedule,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,208.98,,,208.98,86.4325,416.02,fee schedule,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.43,,,398.43,119.991125,581.376,fee schedule,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.43,,,398.43,76.026473,581.376,fee schedule,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.7575,416.02,fee schedule,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,72.5135,416.02,fee schedule,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,462.336,fee schedule,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,92.2695,416.02,fee schedule,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,202.98,,,202.98,96.160741,1043.712,fee schedule,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,252.78,,,252.78,196.52,1195.008,fee schedule,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.29,,,313.29,200.53123,1719.552,fee schedule,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,201.75,,,201.75,96.160741,698.112,fee schedule,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.02,,,254.02,196.52,796.416,fee schedule,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,315.76,,,315.76,200.53123,1704.192,fee schedule,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,200.51,,,200.51,96.160741,575,fee schedule,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,253.19,,,253.19,195.73,1095.936,fee schedule,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.7,,,313.7,200.53123,1057.536,fee schedule,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,377.08,,,377.08,185.92,1624.32,fee schedule,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,493.17,,,493.17,270.27,2337.024,fee schedule,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,377.91,,,377.91,185.92,1706.496,fee schedule,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,423.19,,,423.19,266.73,2183.424,fee schedule,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,377.5,,,377.5,185.92,2035.968,fee schedule,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,481.23,,,481.23,265.17,2031.36,fee schedule,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,545.84,,,545.84,307.53,2399.232,fee schedule,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,496.86,,,496.86,307.93,2175.744,fee schedule,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,542.55,,,542.55,305.58,2443.008,fee schedule,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,64.4315,416.02,fee schedule,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,389.85,,,389.85,200.53123,974.592,fee schedule,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,151.52,,,151.52,96.160741,1050.624,fee schedule,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,257.72,,,257.72,195.33,1198.848,fee schedule,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,301.76,,,301.76,200.53123,1460.736,fee schedule,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,439.65,,,439.65,237.688956,1721.088,fee schedule,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,483.28,,,483.28,372.27,2188.8,fee schedule,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,582.07,,,582.07,399.547552,2114.304,fee schedule,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.82,,,473.82,399.86,2233.344,fee schedule,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.82,,,473.82,399.86,2233.344,fee schedule,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.82,,,473.82,399.86,2233.344,fee schedule,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,76.026473,416.02,fee schedule,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,331.811,2051.3855,other,Non-Reimbursable List
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2051.3855,other,Non-Reimbursable List
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,395.12,2051.3855,other,Non-Reimbursable List
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2051.3855,other,Non-Reimbursable List
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4977.9345,other,Non-Reimbursable List
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4977.9345,other,Non-Reimbursable List
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,38.165,416.02,fee schedule,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,68.697,416.02,fee schedule,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,57.472,416.02,fee schedule,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,31.2055,416.02,fee schedule,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,379.405,1297.92,other,Non-Reimbursable List
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,39.961,416.02,fee schedule,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,38.3895,416.02,fee schedule,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,28.9605,416.02,fee schedule,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,298.8095,1022.208,other,Non-Reimbursable List
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,50.5125,416.02,fee schedule,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,76.026473,416.02,fee schedule,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,42.655,416.02,fee schedule,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,54.1045,416.02,fee schedule,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1322.496,other,Non-Reimbursable List
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,68.697,416.02,fee schedule,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.982,416.02,fee schedule,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,28.9605,416.02,fee schedule,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,199.27,,,199.27,96.160741,736.512,fee schedule,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,249.07,,,249.07,193.37,1065.984,fee schedule,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,332.22,,,332.22,200.53123,1506.048,fee schedule,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,347.46,,,347.46,200.53123,1032.96,fee schedule,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,437.59,,,437.59,237.688956,2217.984,fee schedule,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,478.76,,,478.76,371.09,2254.848,fee schedule,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.66,,,581.66,399.547552,2414.592,fee schedule,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,262.24,,,262.24,204.76,2333.952,fee schedule,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,443.77,,,443.77,340.49,2414.592,fee schedule,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,540.91,,,540.91,399.547552,2350.08,fee schedule,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,49.839,416.02,fee schedule,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126.19,,,126.19,49.839,416.02,fee schedule,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,208.98,,,208.98,86.4325,416.02,fee schedule,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,208.98,,,208.98,86.4325,416.02,fee schedule,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.43,,,398.43,76.026473,581.376,fee schedule,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1241.088,other,Non-Reimbursable List
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126.19,,,126.19,47.8185,416.02,fee schedule,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126.19,,,126.19,54.1045,416.02,fee schedule,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,47.8185,416.02,fee schedule,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.084,416.02,fee schedule,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,58.37,416.02,fee schedule,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,382.548,1308.672,other,Non-Reimbursable List
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,44.6755,416.02,fee schedule,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,51.8595,416.02,fee schedule,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,30.7565,416.02,fee schedule,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,29.185,416.02,fee schedule,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1020.2995,other,Non-Reimbursable List
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,35.471,416.02,fee schedule,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,36.818,416.02,fee schedule,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.533,416.02,fee schedule,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,43.104,416.02,fee schedule,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,200.1,,,200.1,96.160741,743.424,fee schedule,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,253.6,,,253.6,196.51,758.016,fee schedule,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,330.99,,,330.99,200.53123,1461.504,fee schedule,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,389.44,,,389.44,200.53123,903.168,fee schedule,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,434.72,,,434.72,237.688956,2178.048,fee schedule,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,488.64,,,488.64,372.66,1840.128,fee schedule,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,587.42,,,587.42,399.547552,2350.08,fee schedule,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,262.24,,,262.24,205.15,2310.144,fee schedule,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,450.35,,,450.35,345.98,2317.824,fee schedule,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,541.32,,,541.32,399.547552,2379.264,fee schedule,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,476.29,,,476.29,399.86,2290.176,fee schedule,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,476.29,,,476.29,399.86,2290.176,fee schedule,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,476.29,,,476.29,399.86,2290.176,fee schedule,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.93,,,128.93,52.084,416.02,fee schedule,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,237.56,,,237.56,76.026473,416.02,fee schedule,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,237.56,,,237.56,92.045,416.02,fee schedule,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,149.47,,,149.47,96.160741,1112.832,fee schedule,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,256.9,,,256.9,194.55,1218.048,fee schedule,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,301.35,,,301.35,200.53123,1580.544,fee schedule,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,488.63,,,488.63,329.339098,1982.208,fee schedule,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,390.26,,,390.26,200.53123,1040.64,fee schedule,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,181.17,,,181.17,142.38,1050.624,fee schedule,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,306.29,,,306.29,204.61123,1513.728,fee schedule,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,367.62,,,367.62,204.61123,1629.696,fee schedule,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,380.79,,,380.79,237.688956,1810.176,fee schedule,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,542.14,,,542.14,399.547552,3902.208,fee schedule,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,584.54,,,584.54,399.547552,2072.064,fee schedule,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.41,,,473.41,301.425681,1878.528,fee schedule,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.41,,,473.41,301.425681,1878.528,fee schedule,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.41,,,473.41,301.425681,1878.528,fee schedule,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,171.69,,,171.69,76.026473,753.408,fee schedule,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,171.69,,,171.69,128.66,671.232,fee schedule,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,259.7465,888.576,other,Non-Reimbursable List
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,200.53123,703.488,fee schedule,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,194.1925,664.32,fee schedule,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,171.69,,,171.69,128.66,2264.832,fee schedule,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,183.14,907.776,fee schedule,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,200.53123,822.528,fee schedule,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,200.53123,1350.144,fee schedule,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,1026.048,other,Non-Reimbursable List
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,64.8805,416.02,other,Non-Reimbursable List
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,797.184,other,Non-Reimbursable List
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.08,669.696,other,Non-Reimbursable List
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,260.23,2237.184,other,Non-Reimbursable List
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,141.6595,484.608,other,Non-Reimbursable List
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1890.816,other,Non-Reimbursable List
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,434.92,,,434.92,134.4755,499.422,fee schedule,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,434.92,,,434.92,200.53123,1595.904,fee schedule,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,434.92,,,434.92,237.819698,1020.2995,fee schedule,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2172.672,other,Non-Reimbursable List
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1020.2995,other,Non-Reimbursable List
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,171.069,646.6965,other,Non-Reimbursable List
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,171.069,646.6965,other,Non-Reimbursable List
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,121.679,1393.3385,other,Non-Reimbursable List
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5136.771,other,Non-Reimbursable List
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1301.76,other,Non-Reimbursable List
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,285.115,975.36,other,Non-Reimbursable List
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.76,,,308.76,88.902,1706.496,fee schedule,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.76,,,308.76,88.902,1706.496,fee schedule,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,443.77,,,443.77,102.5965,2030.592,fee schedule,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,443.77,,,443.77,102.5965,2030.592,fee schedule,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.2045,836,other,SI=N Exclusions 
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.2045,836,other,SI=N Exclusions 
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.96,,,81.96,19.0825,575,fee schedule,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.96,,,81.96,19.0825,575,fee schedule,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,280.36,,,280.36,58.819,669.696,fee schedule,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,280.36,,,280.36,58.819,669.696,fee schedule,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,374.21,,,374.21,58.819,780.288,fee schedule,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,374.21,,,374.21,58.819,780.288,fee schedule,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,423.6,,,423.6,57.921,824.064,fee schedule,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,423.6,,,423.6,57.921,824.064,fee schedule,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,996.18,39.5,,1128.12,399.86,2536.61118,percent of total billed charges,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,415.06,,,415.06,200.53123,1321.728,fee schedule,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4607.24,,,4607.24,399.86,14233.715,fee schedule,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2717.184,other,Non-Reimbursable List
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,92.2695,416.02,other,Non-Reimbursable List
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4607.24,,,4607.24,399.86,8249.769,fee schedule,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4120.349,other,Non-Reimbursable List
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4120.349,other,Non-Reimbursable List
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4120.349,other,Non-Reimbursable List
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3400.704,other,Non-Reimbursable List
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,367.731,1602.0655,other,Non-Reimbursable List
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,1947.648,other,Non-Reimbursable List
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,260.23,8249.769,other,Non-Reimbursable List
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,260.23,3665.664,other,Non-Reimbursable List
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,105.7395,416.02,other,Non-Reimbursable List
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,324.627,1110.528,other,Non-Reimbursable List
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,294.544,1007.616,other,Non-Reimbursable List
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,189.7025,648.96,other,Non-Reimbursable List
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,167.028,571.392,other,Non-Reimbursable List
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,2241.024,other,Non-Reimbursable List
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,2215.68,other,Non-Reimbursable List
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,681.984,other,Non-Reimbursable List
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,681.984,other,Non-Reimbursable List
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.08,765.696,other,Non-Reimbursable List
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1497.6,other,Non-Reimbursable List
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,668.39,,,668.39,220.908,1393.3385,fee schedule,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,237.15,,,237.15,85.759,416.02,fee schedule,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.024,836,other,Non-Reimbursable List
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.024,836,other,Non-Reimbursable List
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.024,836,other,Non-Reimbursable List
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,94.739,836,other,Non-Reimbursable List
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,94.739,836,other,Non-Reimbursable List
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,94.739,836,other,Non-Reimbursable List
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.41,,,147.41,71.24,712.704,fee schedule,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.08,,,81.08,81.08,1703.424,fee schedule,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.67,,,484.67,189.029,836,fee schedule,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.32,,,180.32,51.4105,575,fee schedule,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,97.2085,416.02,fee schedule,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,99.678,416.02,fee schedule,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,93.6165,416.02,fee schedule,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,221.83,,,221.83,86.4325,416.02,fee schedule,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.32,,,180.32,71.24,416.02,fee schedule,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,103.4945,416.02,fee schedule,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,76.5545,416.02,fee schedule,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,233.97,,,233.97,58.5945,416.02,fee schedule,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,82.616,416.02,fee schedule,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,77.4525,416.02,fee schedule,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,119.991125,456.96,fee schedule,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,64.8805,416.02,fee schedule,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,50.288,416.02,other,SI=N Exclusions 
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,94.5145,416.02,fee schedule,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.086513,547.584,other,SI=N Exclusions 
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,321.16,,,321.16,162.7625,646.6965,fee schedule,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,SI=N Exclusions 
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,68.0235,416.02,fee schedule,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,119.991125,460.8,fee schedule,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,79.6975,416.02,fee schedule,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,98.5555,416.02,fee schedule,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,80.371,416.02,fee schedule,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,65.105,416.02,fee schedule,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,119.991125,443.904,fee schedule,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,32.777,416.02,fee schedule,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,81.9425,416.02,fee schedule,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,321.16,,,321.16,199.512292,772.608,fee schedule,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,81.0445,416.02,fee schedule,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,74.534,416.02,fee schedule,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,102.5965,416.02,fee schedule,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,90.0245,416.02,fee schedule,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,321.16,,,321.16,61.2885,416.02,fee schedule,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,89.8,416.02,fee schedule,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,56.7985,416.02,fee schedule,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,71.24,416.02,fee schedule,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,71.24,416.02,fee schedule,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,225.42,,,225.42,152.8845,775.5705,fee schedule,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,56.3495,416.02,other,Non-Reimbursable List
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,103.27,416.02,other,Non-Reimbursable List
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,166.37,666.624,other,Non-Reimbursable List
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.473,416.02,other,Non-Reimbursable List
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,135.598,463.872,other,Non-Reimbursable List
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,116.9645,416.02,other,Non-Reimbursable List
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,71.391,416.02,other,Non-Reimbursable List
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,116.291,416.02,other,Non-Reimbursable List
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1383.168,other,Non-Reimbursable List
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.344499,1341.696,other,Non-Reimbursable List
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.344499,1347.84,other,Non-Reimbursable List
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,139.8635,575,other,Non-Reimbursable List
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2374.656,other,Non-Reimbursable List
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.67,,,484.67,189.029,836,fee schedule,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.67,,,484.67,189.029,836,fee schedule,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,848.6826,399.547552,1936.896,percent of total billed charges,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1010.5654,399.547552,1936.896,percent of total billed charges,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1117.1516,399.547552,2548.224,percent of total billed charges,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1329.5226,399.547552,2548.224,percent of total billed charges,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,72.0645,416.02,other,Non-Reimbursable List
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,88.2285,416.02,other,Non-Reimbursable List
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.99364,416.02,other,Non-Reimbursable List
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,157.4751,88.2285,416.02,percent of total billed charges,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,186.7262,90.800319,416.02,percent of total billed charges,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,186.7262,90.800319,416.02,percent of total billed charges,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,58.819,416.02,fee schedule,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,48.941,416.02,fee schedule,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,112.699,416.02,fee schedule,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,112.699,416.02,fee schedule,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,230.77,,,230.77,119.991125,441.6,fee schedule,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73.14,,,73.14,25.593,416.02,fee schedule,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,450.35,,,450.35,267.439885,1847.808,fee schedule,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,55.676,416.02,other,Non-Reimbursable List
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,55.676,416.02,other,Non-Reimbursable List
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,236.67,,,236.67,209.9075,1076.394,fee schedule,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,311.41,,,311.41,142.1085,1076.394,fee schedule,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,483.47,,,483.47,220.459,1076.394,fee schedule,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,622.84,,,622.84,235.5005,1397.122,fee schedule,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,38.3895,416.02,other,SI=N Exclusions 
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,483.47,,,483.47,353.5875,1209.6,fee schedule,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,668.39,,,668.39,304.6465,1076.394,fee schedule,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,668.39,,,668.39,358.69,1457.664,fee schedule,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1983.35,,,1983.35,399.86,3675.6585,fee schedule,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,314.9735,1077.504,fee schedule,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,314.9735,1077.504,fee schedule,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,147.9455,1076.394,fee schedule,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,217.9895,1076.394,fee schedule,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,240.4395,1397.122,fee schedule,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,652.52,,,652.52,399.86,2239.93036,fee schedule,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,652.52,,,652.52,270.5225,1076.394,fee schedule,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,652.52,,,652.52,310.708,1076.394,fee schedule,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,652.52,,,652.52,310.708,1397.122,fee schedule,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,176.906,1076.394,fee schedule,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,234.1535,1076.394,fee schedule,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,188.131,1076.394,fee schedule,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,399.86,1596.672,fee schedule,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,200.4785,1076.394,fee schedule,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,214.173,1076.394,fee schedule,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,543.12,,,543.12,215.969,1076.394,fee schedule,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,543.12,,,543.12,246.501,1076.394,fee schedule,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,543.12,,,543.12,200.4785,1076.394,fee schedule,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,543.12,,,543.12,214.622,1076.394,fee schedule,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1410.68,,,1410.68,399.86,3675.6585,fee schedule,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1410.68,,,1410.68,399.86,3675.6585,fee schedule,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1410.68,,,1410.68,399.86,3675.6585,fee schedule,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1410.68,,,1410.68,399.86,3675.6585,fee schedule,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,641.31,,,641.31,356.057,1218.048,fee schedule,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,641.31,,,641.31,375.1395,1283.328,fee schedule,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,458.6,,,458.6,172.1915,1076.394,fee schedule,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,458.6,,,458.6,143.68,1076.394,fee schedule,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,698.2,,,698.2,212.377,1397.122,fee schedule,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,458.6,,,458.6,202.499,1076.394,fee schedule,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,698.2,,,698.2,336.5255,1397.122,fee schedule,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,951.28,,,951.28,399.86,2076.672,fee schedule,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,951.28,,,951.28,356.7305,1397.122,fee schedule,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2191.98,,,2191.98,399.86,3755.52,fee schedule,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,951.28,,,951.28,399.86,1973.76,fee schedule,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,548.12,,,548.12,205.642,1397.122,fee schedule,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,951.28,,,951.28,399.86,3675.6585,fee schedule,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.95,,,690.95,290.054,1076.394,fee schedule,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.95,,,690.95,271.645,1397.122,fee schedule,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.95,,,690.95,201.8255,1397.122,fee schedule,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.95,,,690.95,189.7025,1076.394,fee schedule,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,622.84,,,622.84,194.6415,1076.394,fee schedule,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1043.02,,,1043.02,399.86,3675.6585,fee schedule,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1043.02,,,1043.02,399.86,3675.6585,fee schedule,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1983.35,,,1983.35,399.86,3675.6585,fee schedule,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,491.6589,275.4615,1076.394,percent of total billed charges,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2191.98,,,2191.98,399.86,3982.848,fee schedule,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2191.98,,,2191.98,399.86,5302.272,fee schedule,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2191.98,,,2191.98,399.86,5917.44,fee schedule,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2754.75,,,2754.75,399.86,3675.6585,fee schedule,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2754.75,,,2754.75,399.86,3675.6585,fee schedule,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3091.15,,,3091.15,399.86,4124.5085,fee schedule,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.5735,416.02,other,SI=N Exclusions 
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,491.29,,,491.29,175.559,691.5815,fee schedule,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.52,,,5.02,2.29,24.576,fee schedule,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.72,,,14.13,6.286,21.504,fee schedule,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,343.5,,,381.66,160.742,549.888,fee schedule,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.55,,,7.28,3.33,18.432,fee schedule,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.71,,,5.23,2.4,34.56,fee schedule,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.69,,,61.88,39.73,1313.895373,fee schedule,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.55,,,9.5,4.35,61.44,fee schedule,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.33,,,14.81,6.78,24.576,fee schedule,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11.09,,,12.33,5.6125,19.2,fee schedule,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.91,,,41.01,18.77,98.304,fee schedule,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.46,,,14.96,6.51,121.344,fee schedule,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16.21,,,18.01,6.5105,24.43,fee schedule,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16.05,,,17.83,7.4085,25.344,fee schedule,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28.93,,,32.14,14.71,119.04,fee schedule,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51.86,,,57.62,26.37,193.536,fee schedule,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.98,,,62.2,27.838,95.232,fee schedule,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129.36,,,143.73,64.4315,241.472,fee schedule,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,6.25,92.88556,fee schedule,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.53,,,40.59,2.072,274.944,fee schedule,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.14,,,55.71,2.842,549.235176,fee schedule,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,5.5,93.463636,fee schedule,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,5.85,274.176,fee schedule,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,5.29,274.176,fee schedule,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,3.05,195.186327,fee schedule,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,3.05,65.28,fee schedule,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,3.91,549.235176,fee schedule,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,9.71,238.848,fee schedule,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,3.91,549.235176,fee schedule,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,7.91,218.112,fee schedule,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,2.31,272.64,fee schedule,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,2.072,274.176,fee schedule,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.53,,,40.59,2.45,274.176,fee schedule,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.862,274.176,other,Non-Reimbursable List
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.302,263.69806,fee schedule,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.932,416.02,fee schedule,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.932,93.463636,fee schedule,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.54,499.62884,fee schedule,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,2.702,274.944,fee schedule,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.14,,,55.71,2.072,608.812631,fee schedule,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,2.31,238.848,fee schedule,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.14,,,55.71,2.31,416.02,fee schedule,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.14,,,55.71,2.31,416.02,fee schedule,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.53,,,40.59,2.31,238.848,fee schedule,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.68,229.632,fee schedule,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21.88,,,24.31,11.674,39.936,fee schedule,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.69,,,61.88,47.145,416.02,fee schedule,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.69,,,61.88,34.124,116.736,fee schedule,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24.22,,,26.91,12.32,44.544,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.9,,,1487.7,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.9,,,297.54,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.9,,,297.54,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.9,,,1487.7,139.93,1690.176,fee schedule,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,933.86,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,933.86,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,4669.3,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,4669.3,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,2801.58,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,2801.58,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,933.86,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,4669.3,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,4669.3,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,933.86,287.71,7105.5744,fee schedule,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2739.02,,,2596.26,389.10344,4791.979,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,43.3285,416.02,fee schedule,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.3885,416.02,other,SI=N Exclusions 
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,44.4777,24.9195,416.02,percent of total billed charges,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,671.54688,fee schedule,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,671.54688,fee schedule,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.48,416.02,other,SI=N Exclusions 
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.48,416.02,other,SI=N Exclusions 
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.799745,416.02,other,SI=N Exclusions 
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.799745,416.02,other,SI=N Exclusions 
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.07683,416.02,other,SI=N Exclusions 
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.07683,416.02,other,SI=N Exclusions 
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,881.02656,fee schedule,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,881.02656,fee schedule,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,805.14,,,763.18,91.911626,1316.02176,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,805.14,,,763.18,91.911626,1316.02176,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,805.14,,,763.18,91.911626,1316.02176,fee schedule,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,843.5712,fee schedule,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.135995,416.02,other,SI=N Exclusions 
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.135995,416.02,other,SI=N Exclusions 
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,54.47,416.02,other,SI=N Exclusions 
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,54.47,416.02,other,SI=N Exclusions 
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions 
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions 
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions 
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions 
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions 
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions 
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,566.10816,fee schedule,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,566.10816,fee schedule,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,492.14208,fee schedule,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,492.14208,fee schedule,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,699.04,,,662.6,252.787,1055.807021,fee schedule,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,699.04,,,662.6,398.4875,1363.2,fee schedule,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1734.15,,,1643.76,399.86,3012.096,fee schedule,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1734.15,,,1643.76,399.86,3012.096,fee schedule,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,168.824,1592,fee schedule,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,920,RC,,,outpatient,,,1360,952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,536.68,,,508.71,305.32,1592,fee schedule,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,417.629472,fee schedule,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,417.629472,fee schedule,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.96,416.02,other,Non-Reimbursable List
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,509.03,,,482.5,163,975.36,fee schedule,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,509.03,,,482.5,163,677.376,fee schedule,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,305.07,,,289.17,123.475,422.4,fee schedule,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,34.7975,416.02,fee schedule,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,34.7975,416.02,fee schedule,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,34.7975,416.02,fee schedule,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,142.97,534.528,fee schedule,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,50.5125,416.02,other,SI=N Exclusions 
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,60.3905,416.02,fee schedule,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,51.635,416.02,fee schedule,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,61.17,416.02,fee schedule,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,32.328,416.02,fee schedule,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,29.634,416.02,fee schedule,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,116.5155,416.02,fee schedule,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,14.0245,7.8575,416.02,percent of total billed charges,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,21.3275,416.02,fee schedule,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,28.0625,416.02,fee schedule,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,80.5955,416.02,fee schedule,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,112.25,416.02,fee schedule,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,114.7195,416.02,fee schedule,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,25.593,416.02,fee schedule,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,128.12716,479.602522,fee schedule,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,46.4812,26.042,416.02,percent of total billed charges,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,64.9134,36.369,416.02,percent of total billed charges,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,84.99,559.872,fee schedule,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.01,416.02,other,SI=N Exclusions 
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,610.91,,,579.07,128.12716,662.784,fee schedule,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,610.91,,,579.07,128.12716,662.784,fee schedule,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,13488.384,fee schedule,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13488.384,other,Non-Reimbursable List
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,25715.712,fee schedule,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,25231.872,other,Non-Reimbursable List
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14115.73,,,13380.03,399.86,25024.512,fee schedule,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,20484.864,other,Non-Reimbursable List
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14115.73,,,13380.03,399.86,26793.51305,fee schedule,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,20097.792,other,SI=N Exclusions 
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14115.73,,,13380.03,399.86,20484.864,fee schedule,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,20097.792,other,Non-Reimbursable List
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14115.73,,,13380.03,399.86,19712.256,fee schedule,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,20097.792,other,Non-Reimbursable List
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.133,997.822944,other,Non-Reimbursable List
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.133,997.822944,other,Non-Reimbursable List
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,371.53,,,352.17,292.299,999.936,fee schedule,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,923.32,,,875.2,399.86,1540.608,fee schedule,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,923.32,,,875.2,399.86,1540.608,fee schedule,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,173.5385,593.664,other,SI=N Exclusions 
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,2138.88,other,Non-Reimbursable List
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,2138.88,other,Non-Reimbursable List
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,169.4975,1592,other,Non-Reimbursable List
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,169.4975,1592,other,Non-Reimbursable List
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,13233.408,fee schedule,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,16809.6787,fee schedule,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,16809.6787,fee schedule,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,61.61,,,58.4,25.49469,416.02,fee schedule,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.286,416.02,other,Non-Reimbursable List
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,366.99,,,366.99,108.8825,479.602522,fee schedule,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.63,,,48.63,25.49469,416.02,fee schedule,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.939,416.02,other,Non-Reimbursable List
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,138.06,,,138.06,84.459332,416.02,fee schedule,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153.67,,,145.66,66.75974,416.02,fee schedule,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.1435,416.02,other,Non-Reimbursable List
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,41.157815,934.656,fee schedule,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,41.157815,1442.304,fee schedule,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,41.157815,416.02,fee schedule,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,23.39896,416.02,fee schedule,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,54.1045,1223.3,fee schedule,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,54.1045,1223.3,fee schedule,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,281.81,1040.64,fee schedule,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,281.81,1040.64,fee schedule,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,54.1045,1034.496,fee schedule,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,54.1045,1034.496,fee schedule,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,54.1045,1034.496,fee schedule,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,267.439885,943.104,fee schedule,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,267.439885,943.104,fee schedule,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,491.27,,,465.66,125.9445,465.66,fee schedule,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,491.27,,,465.66,125.9445,465.66,fee schedule,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,491.27,,,465.66,125.9445,465.66,fee schedule,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,224.549385,1354.752,fee schedule,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,224.549385,1354.752,fee schedule,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,336.9745,1152.768,fee schedule,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.024,416.02,other,Non-Reimbursable List
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,72.5135,416.02,other,Non-Reimbursable List
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,86.208,416.02,other,Non-Reimbursable List
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,135.906309,571.392,other,Non-Reimbursable List
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,224.549385,1062.912,fee schedule,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,224.549385,1062.912,fee schedule,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,224.549385,1370.88,fee schedule,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,224.549385,1370.88,fee schedule,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.661,597.504,other,SI=N Exclusions 
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,241.7865,827.136,other,SI=N Exclusions 
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,7870.4,fee schedule,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,7870.4,fee schedule,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,7870.4,fee schedule,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7960.32,other,SI=N Exclusions 
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2671.63,,,2532.39,399.86,2532.39,fee schedule,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2671.63,,,2532.39,399.86,2532.39,fee schedule,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1952.256,other,SI=N Exclusions 
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,228.541,1592,other,SI=N Exclusions 
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,114.495,1592,other,SI=N Exclusions 
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,228.541,1592,other,SI=N Exclusions 
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,SI=N Exclusions 
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5638.7,other,Non-Reimbursable List
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1575.168,other,Non-Reimbursable List
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17980.76,,,17043.62,399.86,40899.072,fee schedule,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17980.76,,,17043.62,399.86,40899.072,fee schedule,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27662.69,,,26220.93,399.86,40542.72,fee schedule,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27662.69,,,26220.93,399.86,40542.72,fee schedule,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6771.4293,399.86,12978.432,percent of total billed charges,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6909.98,other,Non-Reimbursable List
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4525.056,other,Non-Reimbursable List
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2361.6,other,Non-Reimbursable List
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1629.45,,,1544.53,399.86,2367.744,fee schedule,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,701.16,,,664.62,399.86,2367.744,fee schedule,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10671.09667,other,Non-Reimbursable List
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,73.54,934.656,fee schedule,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,184.6,,,174.98,57.2475,416.02,fee schedule,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,184.6,,,174.98,60.8395,416.02,fee schedule,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,199.512292,702.72,fee schedule,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,119.991125,702.72,fee schedule,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,255.2565,873.216,fee schedule,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,149.16,,,141.39,96.086,686,fee schedule,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,213.724,731.136,fee schedule,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153.67,,,145.66,135.906309,702.72,fee schedule,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,250.9,,,237.82,121.132463,686,fee schedule,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,250.9,,,237.82,135.906309,775.5705,fee schedule,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,199.512292,702.72,fee schedule,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,99.0045,686,fee schedule,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,135.906309,686,fee schedule,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,135.906309,686,fee schedule,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,119.991125,702.72,fee schedule,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,170.171,686,fee schedule,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,170.171,686,fee schedule,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,119.991125,702.72,fee schedule,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,183.192,686,fee schedule,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,93.841,686,fee schedule,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,199.512292,702.72,fee schedule,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,86.8815,686,fee schedule,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,119.991125,686,fee schedule,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,145.24,,,137.67,66.2275,416.02,fee schedule,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,233.18,,,221.03,100.127,479.602522,fee schedule,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,415.49,,,393.84,163,710.4,fee schedule,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,242.65,,,230.01,88.004,416.02,fee schedule,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,242.65,,,230.01,88.004,416.02,fee schedule,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.58,,,121.88,40.859,416.02,fee schedule,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.06,,,76.84,59.92,416.02,fee schedule,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.09,,,98.67,98.67,479.602522,fee schedule,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.09,,,98.67,66.2275,416.02,fee schedule,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,145.24,,,137.67,59.4925,416.02,fee schedule,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.123,416.02,other,Non-Reimbursable List
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.205,416.02,other,Non-Reimbursable List
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,43.553,416.02,fee schedule,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,43.553,416.02,other,Non-Reimbursable List
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,335.96,,,22.74,22.74,416.02,fee schedule,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,335.96,,,318.45,185.6615,635.136,fee schedule,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,646.97,,,613.25,185.6615,635.136,fee schedule,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,646.97,,,613.25,185.6615,635.136,fee schedule,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1116.77,,,1058.57,370.2005,1266.432,fee schedule,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1116.77,,,1058.57,355.8325,1217.28,fee schedule,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1116.77,,,1058.57,355.8325,1217.28,fee schedule,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,182.294,623.616,fee schedule,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,215.071,735.744,fee schedule,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,157.3745,538.368,fee schedule,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,176.457,603.648,fee schedule,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,151.5375,518.4,fee schedule,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,381.93,,,381.93,151.5375,829.50194,fee schedule,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.817,570,other,SI=N Exclusions 
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.817,570,other,SI=N Exclusions 
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,30.083,570,other,SI=N Exclusions 
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,30.083,570,other,SI=N Exclusions 
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.4295,570,other,SI=N Exclusions 
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.4295,570,other,SI=N Exclusions 
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99.59,,,94.4,94.4,583.68,fee schedule,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99.59,,,94.4,94.4,570,fee schedule,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99.59,,,94.4,94.4,570,fee schedule,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,197.3355,675.072,other,SI=N Exclusions 
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,156.252,534.528,other,Non-Reimbursable List
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,172.54,,,163.55,74.983,416.02,fee schedule,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,59.14,19.9805,585.854902,fee schedule,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,337.83,,,320.22,93.841,416.02,fee schedule,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,59.14,29.634,585.854902,fee schedule,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,41.0835,416.02,fee schedule,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.4705,416.02,other,Non-Reimbursable List
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,16.16,416.02,fee schedule,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,74.983,416.02,fee schedule,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,69.3705,416.02,fee schedule,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,23.5725,416.02,fee schedule,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,68.0235,416.02,other,Non-Reimbursable List
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,49.839,416.02,fee schedule,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,337.83,,,320.22,155.1295,530.688,fee schedule,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.48,,,504.73,162.538,556.032,fee schedule,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,41.9815,585.854902,fee schedule,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,172.54,,,163.55,70.143083,517.481916,fee schedule,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.48,,,504.73,147.4965,585.854902,fee schedule,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,85.82,,,81.35,34.385146,416.02,fee schedule,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.94,,,35.01,14.38,416.02,fee schedule,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,49.2861,27.6135,416.02,percent of total billed charges,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44.01,,,41.71,14.73,416.02,fee schedule,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,76.23,,,72.26,20.02,416.02,fee schedule,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29.08,,,27.57,14.44,416.02,fee schedule,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29.08,,,27.57,14.44,416.02,fee schedule,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73.88,,,70.03,30.33,416.02,fee schedule,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73.88,,,70.03,30.33,416.02,fee schedule,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.02,,,73,25.8175,416.02,fee schedule,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.02,,,73,25.8175,416.02,fee schedule,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.8175,416.02,other,Non-Reimbursable List
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69.16,,,65.56,27.89,416.02,fee schedule,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69.16,,,65.56,27.89,416.02,fee schedule,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40.08,,,37.99,18.56,416.02,fee schedule,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40.08,,,37.99,18.56,416.02,fee schedule,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,104.182,58.37,416.02,percent of total billed charges,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,104.182,58.37,416.02,percent of total billed charges,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,104.182,58.37,416.02,percent of total billed charges,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.8595,416.02,other,Non-Reimbursable List
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80.95,,,76.73,25.8175,416.02,fee schedule,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80.16,,,75.98,25.8175,416.02,fee schedule,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,88.82,,,84.19,25.8175,416.02,fee schedule,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.02,,,73,23.348,416.02,fee schedule,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.73,,,77.47,34.45,416.02,fee schedule,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,70.74,,,67.05,23.797,416.02,fee schedule,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.15,,,34.27,11.674,416.02,fee schedule,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.635,416.02,other,Non-Reimbursable List
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,Non-Reimbursable List
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,Non-Reimbursable List
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,81.0445,416.02,other,Non-Reimbursable List
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,Non-Reimbursable List
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,74.085,416.02,other,Non-Reimbursable List
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,113.5,,,107.58,70.044,416.02,fee schedule,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,83.42,,,82.56,82.56,416.02,fee schedule,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128,,,126.74,126.37,473.871,fee schedule,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,190.44,,,189.11,179.35,693.026,fee schedule,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,251.79,,,249.6,146.954008,985.784,fee schedule,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24.71,,,22.74,18.1184,416.02,fee schedule,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24.71,,,22.74,18.1184,416.02,fee schedule,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24.71,,,22.74,18.1184,416.02,fee schedule,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59.98,,,55.89,50.2428,416.02,fee schedule,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59.98,,,55.89,50.2428,416.02,fee schedule,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59.98,,,55.89,50.2428,416.02,fee schedule,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.97,,,90.68,90.68,416.02,fee schedule,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.97,,,90.68,90.68,416.02,fee schedule,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,135.27,,,128.59,104.8415,416.02,fee schedule,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,135.27,,,128.59,104.8415,416.02,fee schedule,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,190.46,,,179.41,169.273,685.583,fee schedule,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,190.46,,,179.41,169.273,685.583,fee schedule,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1678.05,39.5,,1247.02,318.748996,2424.576,percent of total billed charges,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1678.05,39.5,,1247.02,318.748996,2424.576,percent of total billed charges,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,204.5195,699.648,other,Non-Reimbursable List
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,204.5195,699.648,other,Non-Reimbursable List
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.31797,416.02,other,Non-Reimbursable List
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51.65,,,48.96,31.31797,416.02,fee schedule,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,310.1418,173.763,2998,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,64.5127,36.1445,2998,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,22389.354,fee schedule,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,294.5145,165.0075,2998,percent of total billed charges,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,1477.69344,other,Non-Reimbursable List
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.30904,416.02,other,Non-Reimbursable List
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.850175,416.02,other,Non-Reimbursable List
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.025285,416.02,other,Non-Reimbursable List
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.025285,416.02,other,Non-Reimbursable List
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.025285,416.02,other,Non-Reimbursable List
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.025285,416.02,other,Non-Reimbursable List
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.401765,416.02,other,Non-Reimbursable List
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.401765,416.02,other,Non-Reimbursable List
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.99,416.02,other,Non-Reimbursable List
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.3553,416.02,other,Non-Reimbursable List
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.3553,416.02,other,Non-Reimbursable List
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.3553,416.02,other,Non-Reimbursable List
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.23,416.02,other,Non-Reimbursable List
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.98576,416.02,other,Non-Reimbursable List
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.98576,416.02,other,Non-Reimbursable List
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.94544,416.02,other,Non-Reimbursable List
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.94544,416.02,other,Non-Reimbursable List
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.94544,416.02,other,Non-Reimbursable List
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.94544,416.02,other,Non-Reimbursable List
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.121435,416.02,other,Non-Reimbursable List
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.121435,416.02,other,Non-Reimbursable List
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.692165,416.02,other,Non-Reimbursable List
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.206745,416.02,other,Non-Reimbursable List
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.206745,416.02,other,Non-Reimbursable List
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04041,416.02,other,Non-Reimbursable List
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04041,416.02,other,Non-Reimbursable List
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04041,416.02,other,Non-Reimbursable List
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04041,416.02,other,Non-Reimbursable List
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.913715,416.02,other,Non-Reimbursable List
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.913715,416.02,other,Non-Reimbursable List
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.913715,416.02,other,Non-Reimbursable List
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.913715,416.02,other,Non-Reimbursable List
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.67604,416.02,other,Non-Reimbursable List
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,416.02,other,Non-Reimbursable List
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,416.02,other,Non-Reimbursable List
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,416.02,other,Non-Reimbursable List
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.600005,416.02,other,Non-Reimbursable List
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.600005,416.02,other,Non-Reimbursable List
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.600005,416.02,other,Non-Reimbursable List
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.087465,416.02,other,Non-Reimbursable List
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.66833,416.02,other,Non-Reimbursable List
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.66833,416.02,other,Non-Reimbursable List
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.122795,416.02,other,Non-Reimbursable List
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.122795,416.02,other,Non-Reimbursable List
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.98009,416.02,other,Non-Reimbursable List
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.21357,416.02,other,Non-Reimbursable List
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.12,416.02,other,Non-Reimbursable List
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.994945,416.02,other,Non-Reimbursable List
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions 
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,291.097925,929.69805,other,Non-Reimbursable List
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2.360123,1.322305,17969.99175,percent of total billed charges,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2.360123,1.322305,17969.99175,percent of total billed charges,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,72522.399,other,Non-Reimbursable List
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,72522.399,other,Non-Reimbursable List
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6992.65577,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6992.65577,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6992.65577,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6992.65577,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions 
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,247.50227,1378.95936,other,Non-Reimbursable List
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,247.50227,1378.95936,other,Non-Reimbursable List
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,247.50227,1378.95936,other,Non-Reimbursable List
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions 
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,144.095325,460.20645,other,Non-Reimbursable List
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23012.49024,other,SI=N Exclusions 
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23012.49024,other,SI=N Exclusions 
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23012.49024,other,SI=N Exclusions 
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23012.49024,other,SI=N Exclusions 
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions 
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions 
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions 
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions 
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions 
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions 
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions 
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions 
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions 
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions 
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions 
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions 
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions 
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions 
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.06164,416.02,other,Non-Reimbursable List
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.06164,416.02,other,Non-Reimbursable List
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.06164,416.02,other,Non-Reimbursable List
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.06164,416.02,other,Non-Reimbursable List
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions 
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions 
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46419.072,other,Non-Reimbursable List
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46419.072,other,Non-Reimbursable List
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46419.072,other,Non-Reimbursable List
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46419.072,other,Non-Reimbursable List
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2621.49888,other,Non-Reimbursable List
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2621.49888,other,Non-Reimbursable List
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2621.49888,other,Non-Reimbursable List
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2621.49888,other,Non-Reimbursable List
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7592.15526,other,Non-Reimbursable List
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7592.15526,other,Non-Reimbursable List
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7592.15526,other,Non-Reimbursable List
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6381.888,other,Non-Reimbursable List
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36549.06,,,36549.06,399.86,42246.08608,fee schedule,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12724.19328,other,SI=N Exclusions 
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions 
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions 
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,170.294475,582.5664,other,SI=N Exclusions 
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.890315,416.02,other,Non-Reimbursable List
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.890315,416.02,other,Non-Reimbursable List
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.890315,416.02,other,Non-Reimbursable List
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.890315,416.02,other,Non-Reimbursable List
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1487.02215,other,SI=N Exclusions 
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1724.0184,other,Non-Reimbursable List
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,267.439885,1479.062,other,Non-Reimbursable List
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2573.3136,other,Non-Reimbursable List
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,77.228,836,other,Non-Reimbursable List
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.71,921.95328,other,Non-Reimbursable List
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-55,NDC,outpatient,1,UN,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions 
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-10,NDC,outpatient,1,UN,7.54,5.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions 
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-51,NDC,outpatient,1,UN,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions 
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-00,NDC,outpatient,1,UN,7.54,5.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions 
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-60,NDC,outpatient,1,UN,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions 
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.92,,,307.2,1.4,836.83584,fee schedule,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.39,416.02,other,Non-Reimbursable List
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,,,,,3.39,416.02,other,Non-Reimbursable List
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,,,,,3.39,416.02,other,Non-Reimbursable List
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.39,416.02,other,Non-Reimbursable List
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.31,416.02,other,Non-Reimbursable List
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.31,416.02,other,Non-Reimbursable List
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.31,416.02,other,Non-Reimbursable List
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.36,1148.18304,other,Non-Reimbursable List
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.36,1148.18304,other,Non-Reimbursable List
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5136.79872,other,Non-Reimbursable List
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5136.79872,other,Non-Reimbursable List
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5136.79872,other,Non-Reimbursable List
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,182.24,5164.04736,other,Non-Reimbursable List
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,182.24,5164.04736,other,Non-Reimbursable List
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,182.24,5164.04736,other,Non-Reimbursable List
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41430.25152,other,Non-Reimbursable List
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41430.25152,other,Non-Reimbursable List
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41430.25152,other,Non-Reimbursable List
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41430.25152,other,Non-Reimbursable List
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,177.26,5164.08576,other,Non-Reimbursable List
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,177.26,5164.08576,other,Non-Reimbursable List
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.39,18739.8144,other,Non-Reimbursable List
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.39,18739.8144,other,Non-Reimbursable List
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.39,18739.8144,other,Non-Reimbursable List
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.39,18739.8144,other,Non-Reimbursable List
SARILUMAB 200 MG/1.14ML SC SOAJ,RX-143091,CDM,C9399,HCPCS,636,RC,00024-5922-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2329.553597,399.86,4927.700596,percent of total billed charges,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.2,1865.41824,other,Non-Reimbursable List
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.2,1865.41824,other,Non-Reimbursable List
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17933.72,,,13380.03,399.86,25024.512,fee schedule,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,26025.216,other,Non-Reimbursable List
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17933.72,,,16999.04,399.86,26793.51305,fee schedule,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17933.72,,,13380.03,399.86,26025.216,fee schedule,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,26025.216,other,SI=N Exclusions 
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17933.72,,,16999.04,399.86,26793.51305,fee schedule,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,26025.216,other,SI=N Exclusions 
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,85.68,19.95,416.02,fee schedule,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.95,416.02,other,SI=N Exclusions 
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,85.68,19.95,416.02,fee schedule,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.95,416.02,other,SI=N Exclusions 
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,59.14,19.95,416.02,fee schedule,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,59.14,19.95,416.02,fee schedule,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,185.6615,1592,other,SI=N Exclusions 
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,386.589,2141,fee schedule,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.349,1592,other,Non-Reimbursable List
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.3685,416.02,other,Non-Reimbursable List
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.44,,,29.8,12.01,416.02,fee schedule,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.83,,,104.83,22.6745,6652,per diem,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.83,,,104.83,22.6745,6652,per diem,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.83,,,104.83,104.83,6652,per diem,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7964.16,other,Non-Reimbursable List
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7964.16,other,Non-Reimbursable List
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7964.16,other,Non-Reimbursable List
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,Non-Reimbursable List
HC Inter Devc Remote 30d,PX-48000092,CDM,G2066,HCPCS,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,47.2826,26.491,416.02,percent of total billed charges,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43.73,,,1067.5,43.27,2936.50176,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions 
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions 
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions 
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3713.134634,336.23,7116.76416,percent of total billed charges,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3713.134634,336.23,7116.76416,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions 
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions 
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions 
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions 
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions 
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions 
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.86,,,17.1,1.61,416.02,fee schedule,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.86,,,17.1,1.61,416.02,fee schedule,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,222.93,,,7616,215.38,15801.64608,fee schedule,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,222.93,,,1088,215.38,15801.64608,fee schedule,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,201.67,,,985.35,194.92,2044.28544,fee schedule,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.35,,,606,5.51,1270.70976,fee schedule,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.83,,,481,4.88,1606.272,fee schedule,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.83,,,481,4.88,1606.272,fee schedule,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.83,,,481,4.88,1606.272,fee schedule,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.89,,,4260,2.98,4260,fee schedule,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.89,,,4260,2.98,4260,fee schedule,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions 
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions 
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.51,416.02,other,SI=N Exclusions 
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.51,416.02,other,SI=N Exclusions 
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.51,416.02,other,SI=N Exclusions 
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.51,416.02,other,SI=N Exclusions 
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.84689,416.02,other,SI=N Exclusions 
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11.13,,,111.3,11.13,416.02,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21.63,,,139.6,23.33,974.33088,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21.63,,,139.6,23.33,974.33088,fee schedule,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions 
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.82,416.02,other,SI=N Exclusions 
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.82,416.02,other,SI=N Exclusions 
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.82,416.02,other,SI=N Exclusions 
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.82,416.02,other,SI=N Exclusions 
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions 
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,9,0.09,416.02,fee schedule,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,3.6,0.09,416.02,fee schedule,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,3.6,0.09,416.02,fee schedule,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,9,0.09,416.02,fee schedule,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,9,0.09,416.02,fee schedule,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,2.25,0.09,416.02,fee schedule,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,2.25,0.09,416.02,fee schedule,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,177.58,,,182.26,174.58,1359.95136,fee schedule,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,177.58,,,364.52,174.58,1359.95136,fee schedule,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,177.58,,,729.04,174.58,1359.95136,fee schedule,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.38,416.02,other,SI=N Exclusions 
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.13,,,623.64,50.93,4488.66816,fee schedule,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.13,,,2078.8,50.93,4488.66816,fee schedule,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.23144,416.02,other,SI=N Exclusions 
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.23144,416.02,other,SI=N Exclusions 
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.23144,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions 
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions 
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19.52,,,188.88,15.67,697.86624,fee schedule,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19.52,,,188.88,15.67,697.86624,fee schedule,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,120.96,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,120.96,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,241.92,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,241.92,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,483.84,20.17,1623.552,fee schedule,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,483.84,20.17,1623.552,fee schedule,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions 
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions 
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions 
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions 
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions 
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.38,,,633,6.15,1343.87712,fee schedule,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.03,416.02,other,SI=N Exclusions 
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.03,416.02,other,SI=N Exclusions 
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.06,416.02,other,SI=N Exclusions 
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.06,416.02,other,SI=N Exclusions 
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6913.11,,,6913.11,60.43,12645.75744,fee schedule,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6913.11,,,6913.11,60.43,12645.75744,fee schedule,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.04,,,5,0.04,416.02,fee schedule,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.04,,,5,0.04,416.02,fee schedule,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.09,,,9,0.08,416.02,fee schedule,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.09,,,9,0.08,416.02,fee schedule,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.09,,,9,0.08,416.02,fee schedule,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.09,,,9,0.08,416.02,fee schedule,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.09,,,9,0.08,416.02,fee schedule,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.09,,,9,0.08,416.02,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1071.97,,,1296.36,399.86,2155.44576,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1071.97,,,1296.36,399.86,2155.44576,fee schedule,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.43,,,4.46,2.68951,416.02,fee schedule,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.43,,,31.22,2.68951,416.02,fee schedule,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.43,,,4.46,2.68951,416.02,fee schedule,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9.4,39.5,,110.39,4.2921885,416.02,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9.4,39.5,,115.91,4.2921885,416.02,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9.4,39.5,,115.91,4.2921885,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,2,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,2,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,9,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,9,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,9,0.01,416.02,fee schedule,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,9,0.01,416.02,fee schedule,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.5,0.01,416.02,fee schedule,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.5,0.01,416.02,fee schedule,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.6,0.01,416.02,fee schedule,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.6,0.01,416.02,fee schedule,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.27,,,4.84,1.22,416.02,fee schedule,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.27,,,4.84,1.22,416.02,fee schedule,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions 
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.24,,,149.6,7.54,500.98176,fee schedule,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions 
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.96,416.02,other,SI=N Exclusions 
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.96,416.02,other,SI=N Exclusions 
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.65,416.02,other,SI=N Exclusions 
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.03,,,154.4,3.89,619.45344,fee schedule,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.03,,,154.4,3.89,619.45344,fee schedule,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.03,,,231.6,3.89,619.45344,fee schedule,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.03,,,231.6,3.89,619.45344,fee schedule,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions 
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.2,,,381.76,92.48,1248.58368,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.2,,,381.76,92.48,1248.58368,fee schedule,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.15189,416.02,other,SI=N Exclusions 
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.15189,416.02,other,SI=N Exclusions 
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,4.04,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,4.04,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,2.02,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,2.02,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,4.04,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,2.39,,,4.04,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,2.39,,,4.04,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,4.04,1.61,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,2.59,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,2.59,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,5.18,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,5.18,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,5.18,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,5.18,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,5.18,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,5.18,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,5.18,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,5.18,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,7.77,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,7.77,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,7.77,2.59,416.02,fee schedule,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,7.77,2.59,416.02,fee schedule,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.74271,416.02,other,SI=N Exclusions 
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.74271,416.02,other,SI=N Exclusions 
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.74271,416.02,other,SI=N Exclusions 
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.86,416.02,other,SI=N Exclusions 
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.86,416.02,other,SI=N Exclusions 
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.86,416.02,other,SI=N Exclusions 
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.40333,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions 
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.61749,416.02,other,SI=N Exclusions 
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.61749,416.02,other,SI=N Exclusions 
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.61749,416.02,other,SI=N Exclusions 
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,60,0.04,416.02,fee schedule,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15.79,,,1521,14.7,4668.927562,fee schedule,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.03,416.02,other,SI=N Exclusions 
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.03,416.02,other,SI=N Exclusions 
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.03,416.02,other,SI=N Exclusions 
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,185.5,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,185.5,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.71,,,185.5,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.71,,,185.5,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.71,,,185.5,1.35,1059.84,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,185.5,1.35,1059.84,fee schedule,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,927.5,1.35,1059.84,fee schedule,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,927.5,1.35,1059.84,fee schedule,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,927.5,1.35,1059.84,fee schedule,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,70.9,6.88,478.41792,fee schedule,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,70.9,6.88,478.41792,fee schedule,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,28.36,6.88,478.41792,fee schedule,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,28.36,6.88,478.41792,fee schedule,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,28.36,6.88,478.41792,fee schedule,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,28.36,6.88,478.41792,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.2,,,18.5,0.46,416.02,fee schedule,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,4.2,,,18.5,0.46,416.02,fee schedule,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.43,,,57.5,1.63,416.02,fee schedule,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.78,416.02,other,SI=N Exclusions 
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.78,416.02,other,SI=N Exclusions 
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.75,,,2906.4,24.19,6805.34016,fee schedule,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.75,,,1453.2,24.19,6805.34016,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1030,HCPCS,636,RC,00009-3073-03,NDC,outpatient,1,ML,22.62,15.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.07819,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-05,NDC,outpatient,1,ML,25.94,18.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.82353,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,00009-3475-03,NDC,outpatient,1,ML,34.96,24.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.82353,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-01,NDC,outpatient,1,ML,25.95,18.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.82353,416.02,other,SI=N Exclusions 
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.03,416.02,other,SI=N Exclusions 
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.295505,416.02,other,SI=N Exclusions 
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.295505,416.02,other,SI=N Exclusions 
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.295505,416.02,other,SI=N Exclusions 
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.29108,416.02,other,SI=N Exclusions 
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.29108,416.02,other,SI=N Exclusions 
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.29108,416.02,other,SI=N Exclusions 
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.28219,416.02,other,SI=N Exclusions 
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.28219,416.02,other,SI=N Exclusions 
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.28219,416.02,other,SI=N Exclusions 
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4777.44,,,4593.57,399.86,9367.9104,fee schedule,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-01,NDC,outpatient,10,ML,44.91,31.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-03,NDC,outpatient,10,ML,44.91,31.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00409-2634-25,NDC,outpatient,10,ML,71.61,50.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-03,NDC,outpatient,1,ML,11.43,8.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-01,NDC,outpatient,1,ML,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-31,NDC,outpatient,1,ML,11.43,8.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-06,NDC,outpatient,0.5,ML,12.4,8.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-11,NDC,outpatient,1,ML,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-96,NDC,outpatient,0.5,ML,12.4,8.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-01,NDC,outpatient,1,ML,11.17,7.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-25,NDC,outpatient,1,ML,11.17,7.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
CONC DILAUDID 10 MG/ML PCA,RX-4080160,CDM,J1170,HCPCS,636,RC,99999-0000-95,NDC,outpatient,50,ML,267.65,187.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions 
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.67,,,247.76,87.49,442.10688,fee schedule,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.3402,416.02,other,SI=N Exclusions 
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,706.17,,,681.74,399.86,1422.7584,fee schedule,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.763505,945.2928,other,SI=N Exclusions 
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.763505,945.2928,other,SI=N Exclusions 
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.763505,945.2928,other,SI=N Exclusions 
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.763505,945.2928,other,SI=N Exclusions 
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.78,416.02,other,SI=N Exclusions 
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.78,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions 
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,225.47,,,6757.8,224.63,13826.65728,fee schedule,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.86,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions 
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69.79,,,83.64,52.988735,416.02,fee schedule,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69.79,,,83.64,52.988735,416.02,fee schedule,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,384.03,,,372.48,339.74932,1162.26048,fee schedule,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.13,,,840,1.1,1903.32672,fee schedule,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions 
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions 
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions 
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions 
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions 
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.18,,,1590,7.3781655,1590,fee schedule,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.18,,,1590,7.3781655,1590,fee schedule,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,18,0.14,1056.72192,fee schedule,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,18,0.14,1056.72192,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,3807.2,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,951.8,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,951.8,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,3807.2,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,951.8,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,951.8,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,1903.6,47.99,8270.99136,fee schedule,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.07,,,97.54,48.47,416.02,fee schedule,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.07,,,97.54,48.47,416.02,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,985.2,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,985.2,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,1970.4,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,3940.8,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,985.2,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,985.2,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,1970.4,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,3940.8,48.81,6450.61632,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79.9,,,765.7,77.77,1531.4,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79.9,,,765.7,77.77,1531.4,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79.9,,,1531.4,77.77,1531.4,fee schedule,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47.74,,,895.8,44.12,1447.31904,fee schedule,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47.74,,,895.8,44.12,1447.31904,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,1778.4,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,1778.4,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,2667.6,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,2667.6,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,36.41,416.02,other,SI=N Exclusions 
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,1122.4,48.52,3264.3072,fee schedule,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,2244.8,48.52,3264.3072,fee schedule,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,1122.4,48.52,3264.3072,fee schedule,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,1122.4,48.52,3264.3072,fee schedule,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,2244.8,48.52,3264.3072,fee schedule,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions 
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.46,,,187.5,90.641875,579.456,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.46,,,187.5,90.641875,579.456,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.46,,,187.5,90.641875,579.456,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.46,,,187.5,90.641875,579.456,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129.67,,,110.76,101.41,468.94848,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129.67,,,110.76,101.41,468.94848,fee schedule,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129.67,,,110.76,101.41,468.94848,fee schedule,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.28,416.02,other,SI=N Exclusions 
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.28,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,Non-Reimbursable List
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,Non-Reimbursable List
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,564.92,,,584.39,333.276985,1140.11904,fee schedule,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,564.92,,,584.39,333.276985,1140.11904,fee schedule,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.56878,416.02,other,SI=N Exclusions 
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.56878,416.02,other,SI=N Exclusions 
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.56878,416.02,other,SI=N Exclusions 
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.56878,416.02,other,SI=N Exclusions 
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28.72,,,74.7,27.14,416.02,fee schedule,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,316.2,,,316.2,85.36837,416.02,fee schedule,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.71,,,326.4,32.22,2399.94624,fee schedule,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17.99,,,34.82,17.18,416.02,fee schedule,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17.99,,,34.82,17.18,416.02,fee schedule,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.23,,,42,0.21,416.02,fee schedule,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.23,,,21,0.21,416.02,fee schedule,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.23,,,42,0.21,416.02,fee schedule,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.23,,,21,0.21,416.02,fee schedule,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.83,416.02,other,SI=N Exclusions 
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.83,416.02,other,SI=N Exclusions 
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions 
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,62.5,0.19,416.02,fee schedule,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.26,,,62.5,0.19,416.02,fee schedule,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.26,,,62.5,0.19,416.02,fee schedule,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,62.5,0.19,416.02,fee schedule,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,2.5,0.19,416.02,fee schedule,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,2.5,0.19,416.02,fee schedule,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,2.5,0.19,416.02,fee schedule,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.4,,,117.5,0.36,416.02,fee schedule,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.4,,,117.5,0.36,416.02,fee schedule,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,738.43,,,1089.82,114.43,1432.33536,fee schedule,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,738.43,,,1089.82,114.43,1432.33536,fee schedule,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.09,,,386.88,1,1207.54176,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,0.5,0.02,416.02,fee schedule,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,0.5,0.02,416.02,fee schedule,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions 
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,7.2,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,0.72,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,0.72,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,0.72,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,0.72,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,3.6,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,3.6,0.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,54.4,1.24,416.02,fee schedule,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,108.8,1.24,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,4.6,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,4.6,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,4.6,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,4.6,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions 
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1673.93,,,1524.34,399.86,10964.15232,fee schedule,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1673.93,,,4573.02,399.86,10964.15232,fee schedule,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions 
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2001,HCPCS,636,RC,00338-0409-03,NDC,outpatient,500,ML,42.7,29.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,Non-Reimbursable List
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions 
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions 
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.30786,416.02,other,SI=N Exclusions 
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.30786,416.02,other,SI=N Exclusions 
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions 
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30.46,,,3017,29.75,6255.52128,fee schedule,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.18518,416.02,other,SI=N Exclusions 
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.18518,416.02,other,SI=N Exclusions 
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.18518,416.02,other,SI=N Exclusions 
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.18518,416.02,other,SI=N Exclusions 
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.07677,506.21952,other,SI=N Exclusions 
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,37.5,0.29,590.53056,fee schedule,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,37.5,0.29,590.53056,fee schedule,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,37.5,0.29,590.53056,fee schedule,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,75,0.29,590.53056,fee schedule,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,75,0.29,590.53056,fee schedule,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,75,0.29,590.53056,fee schedule,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,75,0.29,590.53056,fee schedule,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions 
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.21,,,29,0.18,416.02,fee schedule,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.21,,,29,0.18,416.02,fee schedule,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.41,416.02,other,SI=N Exclusions 
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.41,416.02,other,SI=N Exclusions 
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.41,416.02,other,SI=N Exclusions 
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.41,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.46,1022.48448,other,SI=N Exclusions 
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.46,1022.48448,other,SI=N Exclusions 
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.46,1022.48448,other,SI=N Exclusions 
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.46,1022.48448,other,SI=N Exclusions 
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.72,416.02,other,SI=N Exclusions 
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.72,416.02,other,SI=N Exclusions 
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,25.8,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.34,,,25.8,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.34,,,6.45,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,6.45,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.34,,,12.9,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,12.9,1.3,416.02,fee schedule,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,12.9,1.3,416.02,fee schedule,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,12.9,1.3,416.02,fee schedule,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,12.9,1.3,416.02,fee schedule,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions 
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions 
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38.33,,,1172.7,38.29,2935.67232,fee schedule,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38.33,,,586.35,38.29,2935.67232,fee schedule,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38.33,,,1172.7,38.29,2935.67232,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.317135,416.02,other,SI=N Exclusions 
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.317135,416.02,other,SI=N Exclusions 
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.25,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.5,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.5,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,25,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,25,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,16,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,16,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,16,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,16,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,24,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,24,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,24,0.03,416.02,fee schedule,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,24,0.03,416.02,fee schedule,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,22.5,0.54,416.02,fee schedule,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,22.5,0.54,416.02,fee schedule,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.263845,416.02,other,SI=N Exclusions 
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.263845,416.02,other,SI=N Exclusions 
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,8.8,0.62,416.02,fee schedule,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,8.8,0.62,416.02,fee schedule,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.5,416.02,other,SI=N Exclusions 
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3447.06,,,26456.4,399.86,45671.09376,fee schedule,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.01,416.02,other,SI=N Exclusions 
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.01,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions 
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.739875,416.02,other,SI=N Exclusions 
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.739875,416.02,other,SI=N Exclusions 
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32.77,,,72.5,13.89655,416.02,fee schedule,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32.77,,,72.5,13.89655,416.02,fee schedule,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32.77,,,36.25,13.89655,416.02,fee schedule,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32.77,,,36.25,13.89655,416.02,fee schedule,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions 
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.56,,,24.6,5.42,416.02,fee schedule,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.56,,,24.6,5.42,416.02,fee schedule,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,102.4,1.62,422.7456,fee schedule,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.93,,,102.4,1.62,422.7456,fee schedule,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,102.4,1.62,422.7456,fee schedule,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.93,,,102.4,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,51.2,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,12.8,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,12.8,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,12.8,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,12.8,1.62,422.7456,fee schedule,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,51.2,1.62,422.7456,fee schedule,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7.31,,,9.79,4.40469,416.02,fee schedule,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.586535,416.02,other,SI=N Exclusions 
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.586535,416.02,other,SI=N Exclusions 
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.484535,1082.90304,other,SI=N Exclusions 
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.484535,1082.90304,other,SI=N Exclusions 
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.484535,1082.90304,other,SI=N Exclusions 
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.484535,1082.90304,other,SI=N Exclusions 
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions 
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.43,416.02,other,SI=N Exclusions 
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.43,416.02,other,SI=N Exclusions 
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.95,416.02,other,SI=N Exclusions 
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.95,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions 
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions 
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,493.97,,,493.97,7.136465,1471.59552,fee schedule,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,493.97,,,493.97,7.136465,1471.59552,fee schedule,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,370.9,,,1075.29,357.36,11800.75008,fee schedule,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,370.9,,,5376.45,357.36,11800.75008,fee schedule,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.88,455.8464,other,SI=N Exclusions 
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.88,455.8464,other,SI=N Exclusions 
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.88,455.8464,other,SI=N Exclusions 
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33.72,,,1673,33.71,3005.13792,fee schedule,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33.72,,,1673,33.71,3005.13792,fee schedule,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.16,,,911.25,10.7,2359.38048,fee schedule,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.16,,,1215,10.7,2359.38048,fee schedule,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.81,,,1244.75,95.47,5307.61728,fee schedule,
ROMIPLOSTIM 125 MCG SC SOLR|DISCARDED DRUG NOT ADMINISTERED,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,100.81,,,1149,95.47,5307.61728,fee schedule,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.81,,,2393.75,95.47,5307.61728,fee schedule,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153.16,,,1489.6,139.22,12730.14528,fee schedule,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153.16,,,5958.4,139.22,12730.14528,fee schedule,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.12,416.02,other,SI=N Exclusions 
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.12,416.02,other,SI=N Exclusions 
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.12,416.02,other,SI=N Exclusions 
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.12,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-30,NDC,outpatient,1,UN,20.03,14.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.24,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-28,NDC,outpatient,1,UN,20.03,14.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.24,416.02,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2930,HCPCS,636,RC,00009-0698-01,NDC,outpatient,1,UN,79.04,55.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-25,NDC,outpatient,1,UN,31.87,22.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-22,NDC,outpatient,1,UN,31.87,22.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2930,HCPCS,636,RC,00009-0850-01,NDC,outpatient,1,UN,735.77,515.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2930,HCPCS,636,RC,00009-0758-01,NDC,outpatient,1,UN,87,60.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ ACT-O-VIAL,RX-4081056,CDM,J2930,HCPCS,636,RC,00009-0018-20,NDC,outpatient,1,UN,235.14,164.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions 
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ ACT-O-VIAL,RX-4081057,CDM,J2930,HCPCS,636,RC,00009-0003-02,NDC,outpatient,1,UN,180.85,126.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions 
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91.34,,,178.32,89.15,17236.24704,fee schedule,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91.34,,,178.32,89.15,17236.24704,fee schedule,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91.34,,,8916,89.15,17236.24704,fee schedule,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91.34,,,4458,89.15,17236.24704,fee schedule,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.57,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions 
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,157.47,,,7655,152.7,14884.48512,fee schedule,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.358225,416.02,other,SI=N Exclusions 
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.358225,416.02,other,SI=N Exclusions 
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.358225,416.02,other,SI=N Exclusions 
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.358225,416.02,other,SI=N Exclusions 
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.63291,416.02,other,SI=N Exclusions 
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.63291,416.02,other,SI=N Exclusions 
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.63291,416.02,other,SI=N Exclusions 
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.63291,416.02,other,SI=N Exclusions 
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2065.84,,,2011.27,399.86,4191.12192,fee schedule,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.58,,,31,0.52,416.02,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,201,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,80.4,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,80.4,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,80.4,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,80.4,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,201,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,80.4,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,201,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,80.4,3.83,567.65184,fee schedule,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,201,3.83,567.65184,fee schedule,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,44.72489,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions 
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.95,,,2476,5.91,5460.64128,fee schedule,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.95,,,495.2,5.91,5460.64128,fee schedule,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.95,,,1238,5.91,5460.64128,fee schedule,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.9,416.02,other,SI=N Exclusions 
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.9,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions 
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions 
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions 
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22.88,,,6690,22.26,18370.38336,fee schedule,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.41,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions 
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions 
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.528165,416.02,other,SI=N Exclusions 
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.528165,416.02,other,SI=N Exclusions 
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.15,416.02,other,SI=N Exclusions 
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.15,416.02,other,SI=N Exclusions 
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.15,416.02,other,SI=N Exclusions 
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.15,416.02,other,SI=N Exclusions 
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.29,39.5,,976.12,5.69,1897.8816,percent of total billed charges,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions 
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions 
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions 
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.36,416.02,other,SI=N Exclusions 
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.36,416.02,other,SI=N Exclusions 
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.36,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.51,416.02,other,SI=N Exclusions 
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.51,416.02,other,SI=N Exclusions 
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.43,416.02,other,SI=N Exclusions 
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.43,416.02,other,SI=N Exclusions 
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.73,,,27.72,6.47,416.02,fee schedule,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.73,,,34.65,6.47,416.02,fee schedule,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.73,,,34.65,6.47,416.02,fee schedule,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10347.43296,other,SI=N Exclusions 
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.54,416.02,other,SI=N Exclusions 
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.54,416.02,other,SI=N Exclusions 
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.14,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions 
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.62,416.02,other,SI=N Exclusions 
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.23,416.02,other,SI=N Exclusions 
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.23,416.02,other,SI=N Exclusions 
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.39,416.02,other,SI=N Exclusions 
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.39,416.02,other,SI=N Exclusions 
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.39,416.02,other,SI=N Exclusions 
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.39,416.02,other,SI=N Exclusions 
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.89986,416.02,other,SI=N Exclusions 
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.16,,,1580,2.568211,4642.0992,fee schedule,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.16,,,3160,2.568211,4642.0992,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.27,,,650,1.26,2225.664,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.27,,,1300,1.26,2225.664,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,810,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,810,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,1620,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,1620,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,3240,1.23,3240,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,3240,1.23,3240,fee schedule,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,2410,2.13,24356.18304,fee schedule,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,2410,2.13,24356.18304,fee schedule,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,4820,2.13,24356.18304,fee schedule,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,4820,2.13,24356.18304,fee schedule,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,12050,2.13,24356.18304,fee schedule,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.55,,,750,1.25,2861.568,fee schedule,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.55,,,1500,1.25,2861.568,fee schedule,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.89,,,1855,3.35,3804.8256,fee schedule,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.89,,,1855,3.35,3804.8256,fee schedule,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.36,,,5750,1.94,10651.392,fee schedule,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,73.22,786.36288,other,SI=N Exclusions 
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.536555,416.02,other,SI=N Exclusions 
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.536555,416.02,other,SI=N Exclusions 
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.32,416.02,other,SI=N Exclusions 
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.54,,,77,0.52,416.02,fee schedule,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.54,,,77,0.52,416.02,fee schedule,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,Non-Reimbursable List
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,Non-Reimbursable List
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75.76,,,76.53,69.53663,416.02,fee schedule,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75.76,,,76.53,69.53663,416.02,fee schedule,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5.653877,0.370425,416.02,percent of total billed charges,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1.759073,0.370425,416.02,percent of total billed charges,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1.146002,0.370425,416.02,percent of total billed charges,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1.290254,0.370425,416.02,percent of total billed charges,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1.290254,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,0.661155,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6.242906,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3.498111,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6.242906,0.370425,416.02,percent of total billed charges,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,0.793386,0.370425,416.02,percent of total billed charges,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions 
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions 
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions 
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions 
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions 
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.69,,,222,7.2,2367.72096,fee schedule,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.69,,,222,7.2,2367.72096,fee schedule,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.44,,,41,0.32,416.02,fee schedule,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.44,,,41,0.32,416.02,fee schedule,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.36,,,285.5,5.43,2152.77312,fee schedule,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.36,,,1142,5.43,2152.77312,fee schedule,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.61,,,1586,12.95,3900.27264,fee schedule,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72.46,,,738.1,72.7,7001.856,fee schedule,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72.46,,,2952.4,72.7,7001.856,fee schedule,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.931495,416.02,other,SI=N Exclusions 
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.931495,416.02,other,SI=N Exclusions 
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.73,,,80.15,1.57,905.322979,fee schedule,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.73,,,80.15,1.57,905.322979,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,239.6,,,11105.5,221.96,24824.61696,fee schedule,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,215.5,,,12560.4,206.03,30463.31136,fee schedule,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.41,416.02,other,SI=N Exclusions 
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.41,416.02,other,SI=N Exclusions 
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.63,,,2814,47.04,6870.26688,fee schedule,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75.63,,,1445.6,72.08,3359.0784,fee schedule,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75.63,,,722.8,72.08,3359.0784,fee schedule,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.37,416.02,other,SI=N Exclusions 
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.28,,,167.6,14.25,416.02,fee schedule,
CYCLOPHOSPHAMIDE 1 G IJ SOLR,RX-38270,CDM,J9070,HCPCS,636,RC,00781-3244-94,NDC,outpatient,1,UN,1602.63,1121.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.31,,,179.4,17.09,1230.81984,fee schedule,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9070,HCPCS,636,RC,00781-3233-94,NDC,outpatient,1,UN,1017.09,711.963,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.31,,,89.7,17.09,1230.81984,fee schedule,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9070,HCPCS,636,RC,10019-0957-01,NDC,outpatient,1,UN,1524.13,1066.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.31,,,358.8,17.09,1230.81984,fee schedule,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions 
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions 
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.69078,416.02,other,SI=N Exclusions 
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.69078,416.02,other,SI=N Exclusions 
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.27,,,495.6,4.18,1339.56096,fee schedule,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.27,,,330.4,4.18,1339.56096,fee schedule,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions 
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions 
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.34,416.02,other,SI=N Exclusions 
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,141.29,,,1308.7,128.78,3097.0368,fee schedule,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions 
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,62.498555,604.75,other,SI=N Exclusions 
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.22,,,14.2,1.83,416.02,fee schedule,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.22,,,2.84,1.83,416.02,fee schedule,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.22,,,2.84,1.83,416.02,fee schedule,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.79,416.02,other,SI=N Exclusions 
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.79,416.02,other,SI=N Exclusions 
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.79,416.02,other,SI=N Exclusions 
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.79,416.02,other,SI=N Exclusions 
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,659.53,,,611.35,399.86,5828.5824,fee schedule,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,659.53,,,1834.05,399.86,5828.5824,fee schedule,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.71,,,10.3,2.5,416.02,fee schedule,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.71,,,4.12,2.5,416.02,fee schedule,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.71,,,10.3,2.5,416.02,fee schedule,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133.16,,,1913.55,122.55,12759.31392,fee schedule,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133.16,,,5740.65,122.55,12759.31392,fee schedule,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions 
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions 
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions 
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions 
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions 
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.67,416.02,other,SI=N Exclusions 
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.67,416.02,other,SI=N Exclusions 
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,27.33512,416.02,other,SI=N Exclusions 
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.54,,,166.69,165.86,17420.48256,fee schedule,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.54,,,500.07,165.86,17420.48256,fee schedule,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.54,,,666.76,165.86,17420.48256,fee schedule,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.54,,,666.76,165.86,17420.48256,fee schedule,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,176.78,,,8428,167.93,74965.60128,fee schedule,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,176.78,,,33712,167.93,74965.60128,fee schedule,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-38,NDC,outpatient,0.5,ML,3.4,2.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.27,416.02,other,SI=N Exclusions 
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-37,NDC,outpatient,0.5,ML,3.4,2.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.27,416.02,other,SI=N Exclusions 
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.47721,416.02,other,SI=N Exclusions 
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.47721,416.02,other,SI=N Exclusions 
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73.32,,,583.25,72.53,1721.82528,fee schedule,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions 
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.24,,,1479,12.06,3366.45888,fee schedule,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions 
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2537.07,,,2336.98,399.86,4898.21952,fee schedule,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.66,,,5641,54.81,12451.14624,fee schedule,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.16,,,382.44,42.51,2565.35808,fee schedule,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.16,,,764.88,42.51,2565.35808,fee schedule,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.16,,,764.88,42.51,2565.35808,fee schedule,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.16,,,95.61,42.51,2565.35808,fee schedule,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.11,,,165.56,29.06,416.02,fee schedule,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.6,,,7303.2,30.46,16440.55296,fee schedule,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.6,,,3043,30.46,16440.55296,fee schedule,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.6,,,1217.2,30.46,16440.55296,fee schedule,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74.15,,,7029,70.55,18103.04256,fee schedule,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,158.69,,,1497.2,149.71,14042.8032,fee schedule,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,158.69,,,5988.8,149.71,14042.8032,fee schedule,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.62,,,161,4.18,8613.9648,fee schedule,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.62,,,32.2,4.18,8613.9648,fee schedule,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15.95,,,6476.4,15.37,14335.95648,fee schedule,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,299.13,,,5963.6,356.51,15644.98176,fee schedule,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,71.26,,,1380,68.87,15685.39392,fee schedule,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,71.26,,,6900,68.87,15685.39392,fee schedule,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.68,,,801.9,77.31,10318.18752,fee schedule,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.68,,,4009.5,77.31,10318.18752,fee schedule,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,370.18,,,370.18,223.44,900.08832,fee schedule,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30.75,,,742,32.21,4261.85472,fee schedule,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.5,416.02,other,SI=N Exclusions 
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40.04,,,3834,38.33,13677.02016,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40.04,,,6134.4,38.33,13677.02016,fee schedule,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,78.08,,,1211.85,77.94,3651.07968,fee schedule,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.08,,,2423.7,77.94,3651.07968,fee schedule,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.95,416.02,other,SI=N Exclusions 
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.49,416.02,other,SI=N Exclusions 
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.49,416.02,other,SI=N Exclusions 
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.59,416.02,other,SI=N Exclusions 
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.26,,,1060,1.65,1060,fee schedule,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.26,,,1060,1.65,1060,fee schedule,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.41367,416.02,other,Non-Reimbursable List
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.41367,416.02,other,Non-Reimbursable List
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.41367,416.02,other,Non-Reimbursable List
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.41367,416.02,other,Non-Reimbursable List
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.03643,1222.676,other,Non-Reimbursable List
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.03643,1222.676,other,Non-Reimbursable List
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.03643,1222.676,other,Non-Reimbursable List
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.579235,416.02,other,Non-Reimbursable List
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.579235,416.02,other,Non-Reimbursable List
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.579235,416.02,other,Non-Reimbursable List
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.579235,416.02,other,Non-Reimbursable List
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,29.435422,16.49177,416.02,percent of total billed charges,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,29.435422,16.49177,416.02,percent of total billed charges,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,29.435422,16.49177,416.02,percent of total billed charges,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.76675,416.02,other,Non-Reimbursable List
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.76675,416.02,other,Non-Reimbursable List
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.76675,416.02,other,Non-Reimbursable List
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.76675,416.02,other,Non-Reimbursable List
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,335.72,5377.9968,other,Non-Reimbursable List
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,27.355789,15.326615,416.02,percent of total billed charges,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,37.128862,15.326615,416.02,percent of total billed charges,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,37.128862,15.326615,416.02,percent of total billed charges,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.225885,416.02,other,Non-Reimbursable List
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.225885,416.02,other,Non-Reimbursable List
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.225885,416.02,other,Non-Reimbursable List
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,107.996664,50.613525,568.638,percent of total billed charges,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,107.996664,50.613525,568.638,percent of total billed charges,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,105.728702,50.613525,568.638,percent of total billed charges,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,105.728702,50.613525,568.638,percent of total billed charges,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,90.337815,50.613525,568.638,percent of total billed charges,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,110.03222,50.613525,568.638,percent of total billed charges,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,100.070818,50.613525,568.638,percent of total billed charges,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,93.896031,50.613525,568.638,percent of total billed charges,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.61,416.02,other,Non-Reimbursable List
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,125.65,1058.40384,other,Non-Reimbursable List
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,125.65,1058.40384,other,Non-Reimbursable List
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3409.78176,other,Non-Reimbursable List
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,252.25,3748.3008,other,Non-Reimbursable List
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,252.25,3748.3008,other,Non-Reimbursable List
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.737705,686.06,other,Non-Reimbursable List
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3534.81216,other,Non-Reimbursable List
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3534.81216,other,Non-Reimbursable List
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions 
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,583.0185,326.6475,1117.44,percent of total billed charges,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,181.67,,,172.2,49.4,942.336,fee schedule,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,282.46,,,313.84,123.6995,423.168,fee schedule,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,181.83,,,172.35,71.53,416.02,fee schedule,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,350.65,,,332.37,105.7395,416.02,fee schedule,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,684.69,,,649.01,163,871.3328,fee schedule,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,273.38,,,259.13,136.61,1072.896,fee schedule,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,361.42,,,342.58,163,1384.1308,fee schedule,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1181.08,,,1119.53,163,1119.53,fee schedule,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1557.38,,,1476.21,163,1476.21,fee schedule,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1108.25,,,1050.49,163,2191.8936,fee schedule,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,631.1,,,598.2,142.782,598.2,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1791.37,,,1698,163,1698,fee schedule,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,851.71,,,807.32,163,1747.7512,fee schedule,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,661.98,,,627.48,163,1046.786,fee schedule,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,174.48,,,165.39,49.839,416.02,fee schedule,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1334.98,,,1265.41,163,1265.41,fee schedule,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58.91,,,55.84,19.9805,416.02,fee schedule,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.33,,,255,0.34,726.30528,fee schedule,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.01,416.02,other,SI=N Exclusions 
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.01,416.02,other,SI=N Exclusions 
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.01,416.02,other,SI=N Exclusions 
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.01,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions 
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,416.02,other,SI=N Exclusions 
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,416.02,other,SI=N Exclusions 
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions 
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.55,416.02,other,SI=N Exclusions 
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.55,416.02,other,SI=N Exclusions 
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.55,416.02,other,SI=N Exclusions 
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.55,416.02,other,SI=N Exclusions 
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,136.23,,,724.25,87.98,1653.428703,fee schedule,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,136.23,,,724.25,87.98,1653.428703,fee schedule,
HC Telehealth Originating Site Facility Fee,PX-78000001,CDM,Q3014,HCPCS,780,RC,,,outpatient,,,373,261.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,83.7385,416.02,other,Non-Reimbursable List
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,348.861775,3862.93248,other,Non-Reimbursable List
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,348.861775,3862.93248,other,Non-Reimbursable List
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,348.861775,3862.93248,other,Non-Reimbursable List
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,348.861775,3862.93248,other,Non-Reimbursable List
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,30.42,6716.16,other,Non-Reimbursable List
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.25,659.42016,other,Non-Reimbursable List
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.25,659.42016,other,Non-Reimbursable List
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.96,24594.91584,other,Non-Reimbursable List
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.96,24594.91584,other,Non-Reimbursable List
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.96,24594.91584,other,Non-Reimbursable List
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,8051.0208,other,Non-Reimbursable List
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,8051.0208,other,Non-Reimbursable List
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,8051.0208,other,Non-Reimbursable List
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,46.98,6518.784,other,SI=N Exclusions 
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.16,4034.304,other,Non-Reimbursable List
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.16,4034.304,other,Non-Reimbursable List
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.4745,3643.99872,other,Non-Reimbursable List
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.4745,3643.99872,other,Non-Reimbursable List
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.4745,3643.99872,other,Non-Reimbursable List
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.4745,3643.99872,other,Non-Reimbursable List
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,102.28,3422.3616,other,SI=N Exclusions 
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,102.28,3422.3616,other,SI=N Exclusions 
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,51,0.18,741.12768,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,51,0.18,741.12768,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,51,0.18,741.12768,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,81.6,0.18,741.12768,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,81.6,0.18,741.12768,fee schedule,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.66,,,139.3,13.62,1653.428703,fee schedule,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29.91,,,325.6,27.18,1653.428703,fee schedule,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29.91,,,325.6,27.18,1653.428703,fee schedule,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,14.5,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,14.5,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,21.75,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,21.75,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,29,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,29,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,72.5,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,72.5,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,14.5,7.5,416.02,fee schedule,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,14.5,7.5,416.02,fee schedule,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33.7,,,1881.5,33.59,7269.974281,fee schedule,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33.7,,,376.3,33.59,7269.974281,fee schedule,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21.89,,,264.7,21.29,1590.89664,fee schedule,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.92,438.4896,other,Non-Reimbursable List
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.92,438.4896,other,Non-Reimbursable List
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,Non-Reimbursable List
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.56,416.02,other,Non-Reimbursable List
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.56,416.02,other,Non-Reimbursable List
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.38,416.02,other,Non-Reimbursable List
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.38,416.02,other,Non-Reimbursable List
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.38,416.02,other,Non-Reimbursable List
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.38,416.02,other,Non-Reimbursable List
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.53,2181.7344,other,Non-Reimbursable List
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.53,2181.7344,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-21,NDC,outpatient,650,ME,11.57,8.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-20,NDC,outpatient,650,ME,11.57,8.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-00,NDC,outpatient,650,ME,11.57,8.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-30,NDC,outpatient,650,ME,11.57,8.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,70954-0316-10,NDC,outpatient,50,ML,117.71,82.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,99999-0004-18,NDC,outpatient,2.5,ML,4.86,3.402,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,62332-0001-31,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,00904-7193-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,63739-0645-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FELBAMATE 600 MG ORAL TABS,RX-10025,CDM,S5000,HCPCS,259,RC,72578-0057-16,NDC,outpatient,1,UN,5.99,4.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-61,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-01,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-11,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-06,NDC,outpatient,1,UN,1.66,1.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-15,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,00054-0011-21,NDC,outpatient,1,UN,2.98,2.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-11,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,00054-0010-20,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-15,NDC,outpatient,1,UN,3.66,2.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-11,NDC,outpatient,1,UN,3.66,2.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-11,NDC,outpatient,1,UN,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,00904-6500-61,NDC,outpatient,1,UN,4.03,2.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-01,NDC,outpatient,1,UN,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUCONAZOLE 200 MG ORAL TABS,RX-10045,CDM,S5000,HCPCS,259,RC,00904-6501-61,NDC,outpatient,1,UN,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-11,NDC,outpatient,1,UN,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-15,NDC,outpatient,1,UN,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,64380-0737-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUCYTOSINE 500 MG ORAL CAPS,RX-10052,CDM,S5000,HCPCS,259,RC,42794-0010-08,NDC,outpatient,1,UN,233.01,163.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-15,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,00115-7033-01,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-11,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,51672-4118-06,NDC,outpatient,40,GR,108.41,75.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,16729-0542-35,NDC,outpatient,40,GR,458.18,320.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOXETINE HCL 10 MG ORAL CAPS,RX-10069,CDM,S5000,HCPCS,259,RC,16714-0720-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOXETINE HCL 20 MG ORAL CAPS,RX-10070,CDM,S5000,HCPCS,259,RC,00904-7346-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLURBIPROFEN SODIUM 0.03 % OP SOLN,RX-10080,CDM,S5000,HCPCS,259,RC,69292-0722-25,NDC,outpatient,2.5,ML,140.89,98.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUVOXAMINE MALEATE 50 MG ORAL TABS,RX-10085,CDM,S5000,HCPCS,259,RC,60505-0165-01,NDC,outpatient,1,UN,1.63,1.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOSINOPRIL SODIUM 10 MG ORAL TABS,RX-10094,CDM,S5000,HCPCS,259,RC,69097-0856-05,NDC,outpatient,1,UN,1.76,1.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RITONAVIR 100 MG ORAL TABS,RX-100995,CDM,S5000,HCPCS,259,RC,00074-2340-30,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,00904-6637-61,NDC,outpatient,1,UN,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,60505-0141-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLYBURIDE 2.5 MG ORAL TABS,RX-10126,CDM,S5000,HCPCS,259,RC,00093-8343-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLYCOPYRROLATE 1 MG ORAL TABS,RX-10130,CDM,S5000,HCPCS,259,RC,23155-0606-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-62,NDC,outpatient,1,UN,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-59,NDC,outpatient,1,UN,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 500 MG ORAL TABS,RX-102,CDM,S5000,HCPCS,259,RC,00904-6730-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,64380-0970-25,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,59762-0073-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-07,NDC,outpatient,60,ML,88.11,61.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-11,NDC,outpatient,60,ML,88.11,61.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE MICRONIZED POWD,RX-10217,CDM,S5000,HCPCS,259,RC,51552-0020-05,NDC,outpatient,100,GR,1580.42,1106.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-11,NDC,outpatient,1,UN,4.87,3.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,00904-7046-61,NDC,outpatient,1,UN,3.27,2.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-01,NDC,outpatient,1,UN,4.87,3.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-01,NDC,outpatient,1,UN,3.02,2.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-11,NDC,outpatient,1,UN,3.02,2.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-00,NDC,outpatient,5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-05,NDC,outpatient,5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,51672-2130-08,NDC,outpatient,120,ML,11.22,7.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-05,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-62,NDC,outpatient,5,ML,2.59,1.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-47,NDC,outpatient,473,ML,67.36,47.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-59,NDC,outpatient,5,ML,2.54,1.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,99999-0004-24,NDC,outpatient,5,ML,1.37,0.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-61,NDC,outpatient,5,ML,2.54,1.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-00,NDC,outpatient,5,ML,1398.02,978.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-05,NDC,outpatient,5,ML,1398.02,978.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-02,NDC,outpatient,1,UN,501.97,351.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-01,NDC,outpatient,1,UN,501.97,351.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDOMETHACIN SODIUM 1 MG IV SOLR,RX-10267,CDM,S5000,HCPCS,250,RC,63323-0659-03,NDC,outpatient,1,UN,1192.43,834.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,S5000,HCPCS,259,RC,00002-8315-01,NDC,outpatient,10,ML,61.5,43.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,S5000,HCPCS,259,RC,00002-8215-01,NDC,outpatient,10,ML,61.5,43.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,S5000,HCPCS,259,RC,45802-0732-30,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00713-0326-15,NDC,outpatient,15,GR,50.4,35.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00472-0370-15,NDC,outpatient,15,GR,93.12,65.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,S5000,HCPCS,259,RC,00168-0041-60,NDC,outpatient,60,ML,267,186.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOSORBIDE MONONITRATE 20 MG ORAL TABS,RX-10357,CDM,S5000,HCPCS,259,RC,00228-2620-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISRADIPINE 5 MG ORAL CAPS,RX-10363,CDM,S5000,HCPCS,259,RC,16252-0540-01,NDC,outpatient,1,UN,8.59,6.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ITRACONAZOLE 100 MG ORAL CAPS,RX-10364,CDM,S5000,HCPCS,259,RC,16714-0743-02,NDC,outpatient,1,UN,5.65,3.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,S5000,HCPCS,259,RC,00168-0099-15,NDC,outpatient,15,GR,22.57,15.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,70710-1710-01,NDC,outpatient,1,UN,3.63,2.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,00093-0314-01,NDC,outpatient,1,UN,4.33,3.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-01,NDC,outpatient,1,UN,1.32,0.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-11,NDC,outpatient,1,UN,1.32,0.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-01,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-11,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,00904-5984-26,NDC,outpatient,226,GR,13.08,9.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,16864-0000-18,NDC,outpatient,225,GR,41.06,28.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,30781-7098-79,NDC,outpatient,225,GR,41.06,28.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,63044-0484-09,NDC,outpatient,225,GR,29.04,20.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,51672-1300-05,NDC,outpatient,225,GR,61.08,42.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,57237-0014-01,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,63739-0567-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-01,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-11,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,72603-0115-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-02,NDC,outpatient,1,UN,2.7,1.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-04,NDC,outpatient,1,UN,1.99,1.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-20,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-01,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-11,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-01,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-01,NDC,outpatient,1,UN,2.79,1.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-20,NDC,outpatient,1,UN,2.79,1.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,69238-1835-01,NDC,outpatient,1,UN,1.64,1.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00074-3727-90,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00378-1823-77,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00527-3287-46,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-20,NDC,outpatient,1,UN,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-01,NDC,outpatient,1,UN,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-01,NDC,outpatient,5,ML,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-04,NDC,outpatient,2,ML,4.85,3.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-09,NDC,outpatient,5,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-16,NDC,outpatient,30,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-12,NDC,outpatient,5,ML,4.55,3.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0163-30,NDC,outpatient,30,ML,6.17,4.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-97,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-25,NDC,outpatient,5,ML,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-02,NDC,outpatient,30,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-02,NDC,outpatient,5,ML,4.55,3.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-26,NDC,outpatient,5,ML,4.55,3.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0159-74,NDC,outpatient,5,ML,3.68,2.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-08,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-27,NDC,outpatient,2,ML,4.85,3.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-57,NDC,outpatient,5,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-25,NDC,outpatient,5,ML,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-02,NDC,outpatient,10,ML,10.34,7.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-11,NDC,outpatient,2,ML,4.57,3.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-10,NDC,outpatient,5,ML,11.34,7.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0164-02,NDC,outpatient,2,ML,4.16,2.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0165-05,NDC,outpatient,5,ML,4.63,3.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-05,NDC,outpatient,5,ML,11.34,7.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-12,NDC,outpatient,10,ML,10.34,7.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-25,NDC,outpatient,2,ML,4.57,3.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-07,NDC,outpatient,5,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-09,NDC,outpatient,2,ML,8.69,6.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-01,NDC,outpatient,5,ML,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-01,NDC,outpatient,2,ML,4.57,3.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-04,NDC,outpatient,5,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-27,NDC,outpatient,2,ML,8.69,6.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-03,NDC,outpatient,10,ML,28.48,19.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-97,NDC,outpatient,10,ML,28.48,19.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-16,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-57,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-02,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-27,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-17,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-16,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-17,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-03,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-37,NDC,outpatient,30,ML,30.31,21.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-07,NDC,outpatient,30,ML,30.31,21.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-89,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-01,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-11,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-03,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-27,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-01,NDC,outpatient,20,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-11,NDC,outpatient,20,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-17,NDC,outpatient,10,ML,19.13,13.391,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-02,NDC,outpatient,20,ML,30.18,21.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-27,NDC,outpatient,20,ML,30.18,21.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-89,NDC,outpatient,1,UN,2.51,1.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-01,NDC,outpatient,1,UN,2.51,1.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN,RX-10442,CDM,S5000,HCPCS,250,RC,39822-0151-01,NDC,outpatient,1,ML,1739.29,1217.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,68382-0582-01,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,00093-2179-01,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-03,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,00904-6798-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LISINOPRIL 5 MG ORAL TABS,RX-10451,CDM,S5000,HCPCS,259,RC,00904-6797-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-11,NDC,outpatient,1,UN,1.52,1.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-01,NDC,outpatient,1,UN,1.52,1.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-11,NDC,outpatient,1,UN,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-01,NDC,outpatient,1,UN,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68462-0224-01,NDC,outpatient,1,UN,1,0.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-11,NDC,outpatient,1,UN,11.87,8.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,69918-0301-30,NDC,outpatient,1,UN,6.2,4.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,62559-0265-30,NDC,outpatient,1,UN,10.97,7.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-13,NDC,outpatient,1,UN,11.87,8.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-02,NDC,outpatient,1,UN,223.91,156.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-03,NDC,outpatient,1,UN,223.91,156.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,00904-6852-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,59762-1001-01,NDC,outpatient,1,UN,20.25,14.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,68382-0520-01,NDC,outpatient,1,UN,18.05,12.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAFENIDE ACETATE 85 MG/GM EX CREA,RX-10478,CDM,S5000,HCPCS,259,RC,16571-0723-60,NDC,outpatient,56.7,GR,282.85,197.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-01,NDC,outpatient,3,ML,31.83,22.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,51754-0501-03,NDC,outpatient,3,ML,27.32,19.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,25021-0602-03,NDC,outpatient,3,ML,26.44,18.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-03,NDC,outpatient,3,ML,31.83,22.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM OXIDE 140 MG ORAL CAPS,RX-10490,CDM,S5000,HCPCS,259,RC,60569-0495-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-30,NDC,outpatient,1,UN,1.95,1.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-33,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-05,NDC,outpatient,15,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-03,NDC,outpatient,946,ML,46.31,32.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-04,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-13,NDC,outpatient,946,ML,46.31,32.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE ER 250 MG ORAL CPCR,RX-10533,CDM,S5000,HCPCS,259,RC,54092-0189-81,NDC,outpatient,1,UN,12.49,8.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BROMOCRIPTINE MESYLATE 0.8 MG ORAL TABS,RX-105409,CDM,S5000,HCPCS,259,RC,68012-0258-20,NDC,outpatient,1,UN,23.23,16.261,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,00904-7162-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,99999-0001-42,NDC,outpatient,20,ML,187.97,131.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,00131-5410-72,NDC,outpatient,5,ML,47,32.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-11,NDC,outpatient,1,UN,7.92,5.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-21,NDC,outpatient,1,UN,7.92,5.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,23155-0070-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-01,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-11,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-70,NDC,outpatient,10,ML,17.38,12.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-30,NDC,outpatient,30,ML,36.85,25.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-71,NDC,outpatient,30,ML,36.85,25.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-01,NDC,outpatient,10,ML,18.15,12.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-11,NDC,outpatient,10,ML,18.15,12.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-02,NDC,outpatient,30,ML,28.84,20.188,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-17,NDC,outpatient,10,ML,18.16,12.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-10,NDC,outpatient,10,ML,17.38,12.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-01,NDC,outpatient,10,ML,18.16,12.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-37,NDC,outpatient,30,ML,28.84,20.188,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-16,NDC,outpatient,30,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-01,NDC,outpatient,30,ML,30.98,21.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-01,NDC,outpatient,10,ML,11.21,7.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-02,NDC,outpatient,30,ML,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-04,NDC,outpatient,10,ML,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-17,NDC,outpatient,10,ML,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-11,NDC,outpatient,10,ML,11.21,7.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-37,NDC,outpatient,30,ML,30.98,21.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-17,NDC,outpatient,30,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-31,NDC,outpatient,30,ML,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-11,NDC,outpatient,1,UN,190.6,133.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-94,NDC,outpatient,1,UN,190.6,133.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-08,NDC,outpatient,1,UN,71.96,50.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-02,NDC,outpatient,1,UN,78.51,54.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-01,NDC,outpatient,1,UN,11.25,7.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-20,NDC,outpatient,1,UN,11.25,7.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-01,NDC,outpatient,1,UN,12.79,8.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-20,NDC,outpatient,1,UN,12.79,8.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,S5000,HCPCS,259,RC,16714-0557-01,NDC,outpatient,70,GR,66.67,46.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,50742-0239-01,NDC,outpatient,1,UN,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,62559-0820-01,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,00093-8739-01,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEXILETINE HCL 200 MG ORAL CAPS,RX-10596,CDM,S5000,HCPCS,259,RC,00093-8740-01,NDC,outpatient,1,UN,3.1,2.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,11701-0038-16,NDC,outpatient,85,GR,25.73,18.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,53329-0169-79,NDC,outpatient,85,GR,16.27,11.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MICROFIBRILLAR COLL HEMOSTAT EX PADS,RX-10605,CDM,S5000,HCPCS,259,RC,53276-1010-08,NDC,outpatient,1,UN,496.85,347.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,S5000,HCPCS,250,RC,53276-1010-02,NDC,outpatient,1,GR,993.69,695.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ULIPRISTAL ACETATE 30 MG ORAL TABS,RX-106079,CDM,S5000,HCPCS,259,RC,73302-0456-01,NDC,outpatient,1,UN,159.36,111.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00378-1901-01,NDC,outpatient,1,UN,2.12,1.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00245-0211-11,NDC,outpatient,1,UN,1.99,1.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-20,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-89,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00904-6818-61,NDC,outpatient,1,UN,2.24,1.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-01,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,63739-0145-10,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-01,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-106248,CDM,S5000,HCPCS,259,RC,24208-0830-60,NDC,outpatient,5,ML,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-106249,CDM,S5000,HCPCS,259,RC,61314-0631-36,NDC,outpatient,3.5,GR,69.78,48.846,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,59762-5007-01,NDC,outpatient,1,UN,2.08,1.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-11,NDC,outpatient,1,UN,9.27,6.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,00025-1451-34,NDC,outpatient,1,UN,17.24,12.068,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-01,NDC,outpatient,1,UN,9.27,6.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-11,NDC,outpatient,1,UN,7.19,5.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-01,NDC,outpatient,1,UN,7.19,5.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-16,NDC,outpatient,50,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-01,NDC,outpatient,50,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-61,NDC,outpatient,1,UN,12.92,9.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-56,NDC,outpatient,1,UN,12.92,9.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-55,NDC,outpatient,1,UN,12.92,9.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-82,NDC,outpatient,1,UN,12.92,9.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,99999-0002-18,NDC,outpatient,1,ML,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,00406-8003-30,NDC,outpatient,0.25,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,45802-0112-22,NDC,outpatient,22,GR,13.61,9.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,51672-1312-00,NDC,outpatient,22,GR,11.07,7.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,68462-0180-22,NDC,outpatient,22,GR,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-11,NDC,outpatient,1,UN,3.85,2.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,00591-3670-01,NDC,outpatient,1,UN,1.2,0.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-21,NDC,outpatient,1,UN,3.85,2.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00406-1170-03,NDC,outpatient,1,UN,4.49,3.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-11,NDC,outpatient,1,UN,8.68,6.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00904-7036-04,NDC,outpatient,1,UN,7.95,5.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-21,NDC,outpatient,1,UN,8.68,6.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,68462-0120-90,NDC,outpatient,1,UN,18.98,13.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,62559-0205-90,NDC,outpatient,1,UN,35.49,24.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,68462-0121-90,NDC,outpatient,1,UN,27.58,19.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,42806-0502-09,NDC,outpatient,1,UN,24.73,17.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-1362-23,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-3029-23,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00536-1372-23,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00135-0242-08,NDC,outpatient,1,UN,2.37,1.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-00,NDC,outpatient,1,UN,5.11,3.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-11,NDC,outpatient,1,UN,5.11,3.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,16714-0439-01,NDC,outpatient,1,UN,7.17,5.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-11,NDC,outpatient,1,UN,7.34,5.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-01,NDC,outpatient,1,UN,9.67,6.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-11,NDC,outpatient,1,UN,9.67,6.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,00904-7137-61,NDC,outpatient,1,UN,6.96,4.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-15,NDC,outpatient,1,UN,7.34,5.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-01,NDC,outpatient,1,UN,146.92,102.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,42858-0750-40,NDC,outpatient,1,UN,220.77,154.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-04,NDC,outpatient,1,UN,146.92,102.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-21,NDC,outpatient,1,UN,232.52,162.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-40,NDC,outpatient,1,UN,232.52,162.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLSALAZINE SODIUM 250 MG ORAL CAPS,RX-10773,CDM,S5000,HCPCS,259,RC,00037-6860-10,NDC,outpatient,1,UN,61.39,42.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-00,NDC,outpatient,5,ML,4.92,3.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-05,NDC,outpatient,5,ML,7.15,5.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-40,NDC,outpatient,5,ML,7.15,5.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,99999-0001-41,NDC,outpatient,5,ML,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISACODYL 5 MG ORAL TBEC,RX-1079,CDM,S5000,HCPCS,259,RC,00904-6407-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-12,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-50,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-50,NDC,outpatient,1,UN,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,81421-0021-03,NDC,outpatient,1,UN,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-01,NDC,outpatient,2.5,GR,13.58,9.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-02,NDC,outpatient,2.5,GR,13.58,9.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-26,NDC,outpatient,5,GR,13.67,9.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-30,NDC,outpatient,5,GR,13.67,9.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,99999-0002-27,NDC,outpatient,1,ML,7.21,5.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,00406-8557-30,NDC,outpatient,30,ML,133.24,93.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-55,NDC,outpatient,5,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-05,NDC,outpatient,5,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00904-6966-61,NDC,outpatient,1,UN,1.01,0.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-11,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-23,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-62,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,42858-0001-10,NDC,outpatient,1,UN,1,0.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,10702-0018-50,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAROXETINE HCL 20 MG ORAL TABS,RX-10855,CDM,S5000,HCPCS,259,RC,63739-0963-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISMUTH SUBCARBONATE POWD,RX-1086,CDM,S5000,HCPCS,259,RC,62991-2844-02,NDC,outpatient,100,GR,276.06,193.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,99999-0001-91,NDC,outpatient,30,ML,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,37000-0475-08,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PERMETHRIN 5 % EX CREA,RX-10917,CDM,S5000,HCPCS,259,RC,00472-0242-60,NDC,outpatient,60,GR,76.37,53.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00310-0095-30,NDC,outpatient,1,UN,54.75,38.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,31722-0623-90,NDC,outpatient,1,UN,7.15,5.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-21,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00378-1905-77,NDC,outpatient,1,UN,17.44,12.208,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,42571-0259-30,NDC,outpatient,1,UN,4.47,3.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-11,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOXYBENZAMINE HCL 10 MG ORAL CAPS,RX-10945,CDM,S5000,HCPCS,259,RC,66993-0066-02,NDC,outpatient,1,UN,73.53,51.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-10,NDC,outpatient,1,UN,1233.54,863.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-01,NDC,outpatient,1,UN,1208.89,846.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LINAGLIPTIN 5 MG ORAL TABS,RX-109773,CDM,S5000,HCPCS,259,RC,00597-0140-61,NDC,outpatient,1,UN,56.14,39.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RILPIVIRINE HCL 25 MG ORAL TABS,RX-109909,CDM,S5000,HCPCS,259,RC,59676-0278-01,NDC,outpatient,1,UN,209.04,146.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,00904-7199-07,NDC,outpatient,1,UN,3.73,2.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-95,NDC,outpatient,1,UN,4.05,2.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-25,NDC,outpatient,1,UN,4.05,2.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYTOIN SODIUM EXTENDED 30 MG ORAL CAPS,RX-11019,CDM,S5000,HCPCS,259,RC,00071-3740-66,NDC,outpatient,1,UN,5.97,4.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-94,NDC,outpatient,1,UN,227.6,159.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-11,NDC,outpatient,1,UN,227.6,159.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FIDAXOMICIN 200 MG ORAL TABS,RX-110360,CDM,S5000,HCPCS,259,RC,52015-0080-01,NDC,outpatient,1,UN,501.77,351.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TICAGRELOR 90 MG ORAL TABS,RX-110427,CDM,S5000,HCPCS,259,RC,00186-0777-39,NDC,outpatient,1,UN,30.77,21.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00536-4306-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00904-2500-91,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLYSACCHARIDE IRON COMPLEX 150 MG ORAL CAPS,RX-11050,CDM,S5000,HCPCS,259,RC,00904-5395-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-33,NDC,outpatient,1,UN,8.47,5.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,00178-0610-01,NDC,outpatient,1,UN,7.92,5.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-32,NDC,outpatient,1,UN,8.47,5.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,68180-0678-01,NDC,outpatient,60,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,27241-0139-09,NDC,outpatient,60,ML,35.52,24.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,00004-0822-05,NDC,outpatient,60,ML,624.52,437.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,99999-0000-41,NDC,outpatient,5,ML,52.63,36.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAVASTATIN SODIUM 10 MG ORAL TABS,RX-11110,CDM,S5000,HCPCS,259,RC,00904-5891-61,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-20,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,00904-5892-61,NDC,outpatient,1,UN,2.3,1.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-01,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-01,NDC,outpatient,1,UN,2.64,1.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-11,NDC,outpatient,1,UN,2.64,1.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,S5000,HCPCS,259,RC,00574-7226-12,NDC,outpatient,1,UN,26.18,18.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-06,NDC,outpatient,1,UN,43.38,30.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-12,NDC,outpatient,1,UN,43.38,30.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,S5000,HCPCS,259,RC,00713-0526-12,NDC,outpatient,1,UN,43.38,30.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPAFENONE HCL 150 MG ORAL TABS,RX-11146,CDM,S5000,HCPCS,259,RC,00591-0582-01,NDC,outpatient,1,UN,1.95,1.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPAFENONE HCL 225 MG ORAL TABS,RX-11147,CDM,S5000,HCPCS,259,RC,00591-0583-01,NDC,outpatient,1,UN,1.32,0.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,00904-6622-61,NDC,outpatient,1,UN,3.64,2.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,68382-0659-06,NDC,outpatient,1,UN,1.59,1.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOSTIGMINE BROMIDE ER 180 MG ORAL TBCR,RX-11240,CDM,S5000,HCPCS,259,RC,47781-0335-30,NDC,outpatient,1,UN,71.76,50.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIMETHAMINE 25 MG ORAL TABS,RX-11246,CDM,S5000,HCPCS,259,RC,43598-0672-01,NDC,outpatient,1,UN,1019.51,713.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-00,NDC,outpatient,2,ML,92.93,65.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-05,NDC,outpatient,2,ML,92.93,65.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RAMIPRIL 1.25 MG ORAL CAPS,RX-11258,CDM,S5000,HCPCS,259,RC,68382-0144-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,68382-0146-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,57237-0224-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-11,NDC,outpatient,1,UN,9.33,6.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-21,NDC,outpatient,1,UN,9.33,6.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,68180-0157-01,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIBAVIRIN 200 MG ORAL CAPS,RX-11286,CDM,S5000,HCPCS,259,RC,65862-0290-84,NDC,outpatient,1,UN,5.94,4.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFABUTIN 150 MG ORAL CAPS,RX-11290,CDM,S5000,HCPCS,259,RC,59762-1350-01,NDC,outpatient,1,UN,47.58,33.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,63323-0351-20,NDC,outpatient,1,UN,246.71,172.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,00068-0597-01,NDC,outpatient,1,UN,360.5,252.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,67457-0445-60,NDC,outpatient,1,UN,242,169.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-21,NDC,outpatient,1,UN,10.17,7.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-11,NDC,outpatient,1,UN,10.17,7.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-11,NDC,outpatient,1,UN,6.25,4.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-01,NDC,outpatient,1,UN,6.25,4.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-01,NDC,outpatient,1,UN,9.15,6.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-11,NDC,outpatient,1,UN,9.15,6.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-113082,CDM,S5000,HCPCS,259,RC,00487-5901-99,NDC,outpatient,1,UN,5.79,4.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,65628-0070-03,NDC,outpatient,5,ML,27.75,19.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,99999-9003-64,NDC,outpatient,5,ML,27.75,19.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-04,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,68180-0352-09,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,76282-0213-18,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-01,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-11,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,00904-6925-61,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,63402-0302-30,NDC,outpatient,1,UN,165.29,115.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,67877-0638-30,NDC,outpatient,1,UN,1.86,1.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,16729-0346-10,NDC,outpatient,1,UN,5,3.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,S5000,HCPCS,259,RC,12870-0001-01,NDC,outpatient,10,UN,28.31,19.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-00,NDC,outpatient,30,ML,19.63,13.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-30,NDC,outpatient,30,ML,19.63,13.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-04,NDC,outpatient,1000,ML,15.82,11.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-03,NDC,outpatient,500,ML,11.87,8.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,S5000,HCPCS,259,RC,24208-0276-15,NDC,outpatient,15,ML,65.35,45.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-11,NDC,outpatient,1,UN,4.36,3.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-01,NDC,outpatient,1,UN,4.36,3.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,62135-0436-90,NDC,outpatient,1,UN,16.45,11.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,00093-2210-01,NDC,outpatient,1,UN,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,29033-0003-05,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-01,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-20,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,59762-0401-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,00527-1318-01,NDC,outpatient,1,UN,19.38,13.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,62559-0721-01,NDC,outpatient,1,UN,4.45,3.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-01,NDC,outpatient,2,ML,164.48,115.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-10,NDC,outpatient,2,ML,164.48,115.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-21,NDC,outpatient,1,UN,883.55,618.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-22,NDC,outpatient,1,UN,883.55,618.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,S5000,HCPCS,250,RC,60793-0215-05,NDC,outpatient,1,UN,195.76,137.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,64980-0513-05,NDC,outpatient,5,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,60758-0802-05,NDC,outpatient,5,ML,11.17,7.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,60758-0801-05,NDC,outpatient,5,ML,22.48,15.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,64980-0514-05,NDC,outpatient,5,ML,21.94,15.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,S5000,HCPCS,259,RC,00078-0876-01,NDC,outpatient,3.5,GR,1115.32,780.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,S5000,HCPCS,259,RC,24208-0295-25,NDC,outpatient,2.5,ML,173.64,121.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,59212-0002-01,NDC,outpatient,1,UN,60.49,42.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,66993-0831-02,NDC,outpatient,1,UN,36.58,25.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,S5000,HCPCS,259,RC,61314-0044-75,NDC,outpatient,7.5,ML,948.02,663.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,24208-0315-10,NDC,outpatient,10,ML,47.84,33.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,61314-0628-10,NDC,outpatient,10,ML,43.88,30.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TABS,RX-11599,CDM,S5000,HCPCS,259,RC,00904-2725-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-01,NDC,outpatient,1,UN,15.37,10.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-11,NDC,outpatient,1,UN,15.37,10.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-01,NDC,outpatient,1,UN,11.52,8.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-10,NDC,outpatient,1,UN,11.52,8.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-01,NDC,outpatient,1,UN,41.49,29.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-10,NDC,outpatient,1,UN,41.49,29.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,RX-116728,CDM,S5000,HCPCS,259,RC,00597-0024-02,NDC,outpatient,4,GR,2012.08,1408.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIDOVUDINE 100 MG ORAL CAPS,RX-11692,CDM,S5000,HCPCS,259,RC,65862-0107-01,NDC,outpatient,1,UN,6.23,4.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIDOVUDINE 10 MG/ML ORAL SYRP,RX-11693,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,3.1,2.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZOLPIDEM TARTRATE 5 MG ORAL TABS,RX-11701,CDM,S5000,HCPCS,259,RC,00904-6082-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LINACLOTIDE 145 MCG ORAL CAPS,RX-117352,CDM,S5000,HCPCS,259,RC,00456-1201-30,NDC,outpatient,1,UN,74.11,51.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-16,NDC,outpatient,1,UN,6.86,4.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-93,NDC,outpatient,1,UN,6.86,4.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-01,NDC,outpatient,1,UN,8.83,6.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-07,NDC,outpatient,1,UN,8.83,6.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-23,NDC,outpatient,1,UN,4.35,3.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-62,NDC,outpatient,1,UN,4.35,3.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00904-6558-61,NDC,outpatient,1,UN,5.15,3.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-01,NDC,outpatient,1,UN,1.46,1.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-31,NDC,outpatient,1,UN,6.17,4.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-21,NDC,outpatient,1,UN,6.17,4.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-01,NDC,outpatient,10,ML,102.35,71.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-03,NDC,outpatient,10,ML,102.35,71.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-10,NDC,outpatient,10,ML,30.13,21.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-11,NDC,outpatient,10,ML,30.26,21.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-01,NDC,outpatient,10,ML,30.13,21.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-10,NDC,outpatient,10,ML,30.26,21.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00228-4270-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,63304-0450-01,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-62,NDC,outpatient,1,UN,2.2,1.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-23,NDC,outpatient,1,UN,2.2,1.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-62,NDC,outpatient,1,UN,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-23,NDC,outpatient,1,UN,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5649-01,NDC,outpatient,10,ML,39.65,27.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-09,NDC,outpatient,10,ML,3.96,2.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-28,NDC,outpatient,10,ML,3.96,2.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-02,NDC,outpatient,10,ML,3.96,2.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
APIXABAN 5 MG ORAL TABS,RX-119614,CDM,S5000,HCPCS,259,RC,00003-0894-31,NDC,outpatient,1,UN,6.17,4.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,00023-5853-18,NDC,outpatient,1,UN,15.96,11.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,59762-0117-01,NDC,outpatient,1,UN,10.4,7.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-33,NDC,outpatient,1,UN,23.14,16.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-32,NDC,outpatient,1,UN,23.14,16.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-11,NDC,outpatient,1,UN,1.73,1.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-01,NDC,outpatient,1,UN,1.73,1.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,62332-0025-31,NDC,outpatient,1,UN,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,68462-0721-01,NDC,outpatient,1,UN,5.92,4.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL ER 14 MG ORAL CP24,RX-121474,CDM,S5000,HCPCS,259,RC,00456-3414-33,NDC,outpatient,1,UN,7.56,5.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL ER 21 MG ORAL CP24,RX-121475,CDM,S5000,HCPCS,259,RC,00456-3421-33,NDC,outpatient,1,UN,7.56,5.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL ER 28 MG ORAL CP24,RX-121476,CDM,S5000,HCPCS,259,RC,00456-3428-33,NDC,outpatient,1,UN,63.71,44.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,55494-0100-10,NDC,outpatient,1,UN,13.41,9.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,70505-0100-10,NDC,outpatient,1,UN,13.18,9.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
QUINIDINE GLUCONATE ER 324 MG ORAL TBCR,RX-12197,CDM,S5000,HCPCS,259,RC,53489-0141-01,NDC,outpatient,1,UN,24.15,16.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-95,NDC,outpatient,1,UN,3.98,2.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-25,NDC,outpatient,1,UN,3.98,2.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-01,NDC,outpatient,1,UN,3.02,2.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-11,NDC,outpatient,1,UN,3.02,2.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,57664-0395-88,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-01,NDC,outpatient,1,UN,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-11,NDC,outpatient,1,UN,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-39,NDC,outpatient,2.5,ML,560.63,392.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-40,NDC,outpatient,2.5,ML,560.63,392.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IRON-VITAMIN C 65-125 MG ORAL TABS,RX-122332,CDM,S5000,HCPCS,259,RC,63736-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL ER 10 MG ORAL T12A,RX-122363,CDM,S5000,HCPCS,259,RC,59011-0410-20,NDC,outpatient,1,UN,22.52,15.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-10,NDC,outpatient,1,UN,40.9,28.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-20,NDC,outpatient,1,UN,41.94,29.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL ER 40 MG ORAL T12A,RX-122368,CDM,S5000,HCPCS,259,RC,59011-0440-20,NDC,outpatient,1,UN,71.8,50.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOLUTEGRAVIR SODIUM 50 MG ORAL TABS,RX-122784,CDM,S5000,HCPCS,259,RC,49702-0228-13,NDC,outpatient,1,UN,324.81,227.367,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,65162-0082-03,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,16729-0348-10,NDC,outpatient,1,UN,5,3.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-11,NDC,outpatient,30,ML,57.68,40.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-01,NDC,outpatient,4,ML,26.92,18.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-30,NDC,outpatient,30,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-61,NDC,outpatient,3,ML,9.75,6.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-03,NDC,outpatient,30,ML,57.68,40.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-25,NDC,outpatient,4,ML,26.92,18.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-04,NDC,outpatient,4,ML,17.02,11.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-60,NDC,outpatient,3,ML,9.75,6.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-22,NDC,outpatient,30,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-22,NDC,outpatient,4,ML,17.02,11.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-41,NDC,outpatient,2,ML,9.94,6.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-02,NDC,outpatient,2,ML,21.6,15.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-03,NDC,outpatient,2,ML,9.94,6.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-03,NDC,outpatient,2,ML,11.79,8.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-42,NDC,outpatient,2,ML,21.6,15.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-02,NDC,outpatient,2,ML,11.79,8.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,51672-4070-08,NDC,outpatient,2.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,99999-0004-13,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,61314-0643-05,NDC,outpatient,5,ML,42.15,29.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,70069-0131-01,NDC,outpatient,5,ML,22.25,15.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EXENATIDE 5 MCG/0.02ML SC SOPN,RX-124738,CDM,S5000,HCPCS,259,RC,00310-6512-01,NDC,outpatient,1.2,ML,2102.55,1471.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EXENATIDE 10 MCG/0.04ML SC SOPN,RX-124739,CDM,S5000,HCPCS,259,RC,00310-6524-01,NDC,outpatient,2.4,ML,2102.55,1471.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-12,NDC,outpatient,3,ML,1117.4,782.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-13,NDC,outpatient,3,ML,1117.41,782.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,00555-0899-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,42806-0087-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN 0.3 % OP OINT,RX-125351,CDM,S5000,HCPCS,259,RC,00078-0813-01,NDC,outpatient,3.5,GR,1047.63,733.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL LIQD,RX-12556,CDM,S5000,HCPCS,259,RC,00904-6985-20,NDC,outpatient,2.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-83,NDC,outpatient,2.5,ML,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-01,NDC,outpatient,2.5,ML,1.51,1.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-60,NDC,outpatient,2.5,ML,1.12,0.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-79,NDC,outpatient,2.5,ML,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00378-7970-93,NDC,outpatient,2.5,ML,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,76204-0100-01,NDC,outpatient,2.5,ML,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-125849,CDM,S5000,HCPCS,259,RC,00536-1186-12,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAFFEINE 200 MG ORAL TABS,RX-1259,CDM,S5000,HCPCS,259,RC,46017-0018-40,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DANTROLENE SODIUM 250 MG IV SUSR,RX-126042,CDM,S5000,HCPCS,250,RC,42367-0540-32,NDC,outpatient,1,UN,5868.29,4107.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-30,NDC,outpatient,1,UN,55.29,38.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-37,NDC,outpatient,1,UN,55.29,38.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EMPAGLIFLOZIN 25 MG ORAL TABS,RX-126078,CDM,S5000,HCPCS,259,RC,00597-0153-37,NDC,outpatient,1,UN,55.29,38.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-10,NDC,outpatient,2,ML,107.33,75.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-01,NDC,outpatient,2,ML,107.33,75.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TERBINAFINE HCL 250 MG ORAL TABS,RX-12724,CDM,S5000,HCPCS,259,RC,65862-0079-30,NDC,outpatient,1,UN,1.29,0.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMTERENE-HCTZ 37.5-25 MG ORAL CAPS,RX-12729,CDM,S5000,HCPCS,259,RC,00781-2074-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE IN NACL 20-0.9 MG/50ML-% IV SOLN,RX-12735,CDM,S5000,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-05,NDC,outpatient,5,ML,13.49,9.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-04,NDC,outpatient,5,ML,13.49,9.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-05,NDC,outpatient,5,ML,45.71,31.997,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-04,NDC,outpatient,5,ML,45.71,31.997,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,99999-0002-29,NDC,outpatient,5,ML,70.67,49.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE 7.5 MCG/HR TD PTWK,RX-127562,CDM,S5000,HCPCS,259,RC,42858-0353-40,NDC,outpatient,1,UN,309.07,216.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-95,NDC,outpatient,1,UN,10.51,7.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-25,NDC,outpatient,1,UN,10.51,7.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,00527-1313-01,NDC,outpatient,1,UN,4.2,2.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,RX-128423,CDM,S5000,HCPCS,259,RC,00597-0100-51,NDC,outpatient,4,GR,308.39,215.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENTOSAN POLYSULFATE SODIUM 100 MG ORAL CAPS,RX-12912,CDM,S5000,HCPCS,259,RC,50458-0098-01,NDC,outpatient,1,UN,46.46,32.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-01,NDC,outpatient,1,UN,4.95,3.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,00904-7097-61,NDC,outpatient,1,UN,4.43,3.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-20,NDC,outpatient,1,UN,4.95,3.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOMEBORO EX PACK,RX-129475,CDM,S5000,HCPCS,259,RC,57074-0001-77,NDC,outpatient,1,UN,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DARUNAVIR-COBICISTAT 800-150 MG ORAL TABS,RX-129730,CDM,S5000,HCPCS,259,RC,59676-0575-30,NDC,outpatient,1,UN,354.92,248.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-95,NDC,outpatient,2,ML,130.52,91.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-72,NDC,outpatient,2,ML,130.52,91.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-90,NDC,outpatient,1,UN,23.54,16.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-04,NDC,outpatient,1,UN,23.54,16.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-01,NDC,outpatient,1,UN,42.28,29.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-24,NDC,outpatient,1,UN,23.2,16.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-01,NDC,outpatient,4,ML,15.67,10.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,25021-0316-04,NDC,outpatient,4,ML,19.53,13.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-00,NDC,outpatient,4,ML,24.37,17.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-01,NDC,outpatient,4,ML,19.72,13.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-07,NDC,outpatient,4,ML,19.72,13.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-10,NDC,outpatient,4,ML,15.67,10.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-14,NDC,outpatient,4,ML,23.45,16.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-04,NDC,outpatient,4,ML,24.37,17.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-04,NDC,outpatient,4,ML,23.45,16.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,00904-3232-92,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,20555-0005-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,41167-0058-40,NDC,outpatient,1,UN,6.13,4.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,70512-0812-30,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,00536-1202-07,NDC,outpatient,1,UN,3.11,2.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,59762-1210-03,NDC,outpatient,1,UN,2.76,1.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,68180-0604-06,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-34,NDC,outpatient,10,ML,55.67,38.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-10,NDC,outpatient,10,ML,41.92,29.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-11,NDC,outpatient,10,ML,55.67,38.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,76329-3304-01,NDC,outpatient,10,ML,39.08,27.356,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-40,NDC,outpatient,10,ML,41.92,29.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-01,NDC,outpatient,1,UN,5.2,3.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,68462-0260-01,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-11,NDC,outpatient,1,UN,5.2,3.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-131078,CDM,S5000,HCPCS,259,RC,00597-0155-70,NDC,outpatient,4,GR,308.39,215.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,00904-5823-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG ORAL TABS,RX-131233,CDM,S5000,HCPCS,259,RC,61958-1901-01,NDC,outpatient,1,UN,572.84,400.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,63739-0077-10,NDC,outpatient,1,UN,4,2.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-01,NDC,outpatient,1,UN,4.3,3.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-11,NDC,outpatient,1,UN,4.3,3.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,00904-6565-61,NDC,outpatient,1,UN,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SACUBITRIL-VALSARTAN 24-26 MG ORAL TABS,RX-131630,CDM,S5000,HCPCS,259,RC,00078-0659-20,NDC,outpatient,1,UN,46.68,32.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SACUBITRIL-VALSARTAN 49-51 MG ORAL TABS,RX-131631,CDM,S5000,HCPCS,259,RC,00078-0777-20,NDC,outpatient,1,UN,46.68,32.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SACUBITRIL-VALSARTAN 97-103 MG ORAL TABS,RX-131632,CDM,S5000,HCPCS,259,RC,00078-0696-20,NDC,outpatient,1,UN,46.68,32.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMINOCAPROIC ACID 0.25 GM/ML ORAL SOLN,RX-131645,CDM,S5000,HCPCS,259,RC,99999-0001-90,NDC,outpatient,5,ML,202.39,141.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL ER 120 MG ORAL TBCR,RX-13184,CDM,S5000,HCPCS,259,RC,68462-0292-01,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE (PF) 0.75% -1:200000 IJ SOLN,RX-132205,CDM,S5000,HCPCS,250,RC,63323-0460-37,NDC,outpatient,30,ML,34.71,24.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TICAGRELOR 60 MG ORAL TABS,RX-132286,CDM,S5000,HCPCS,259,RC,00186-0776-60,NDC,outpatient,1,UN,30.77,21.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,69374-0982-55,NDC,outpatient,5,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-1119-44,NDC,outpatient,5,ML,20.39,14.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-9119-44,NDC,outpatient,5,ML,27.82,19.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70004-0430-09,NDC,outpatient,5,ML,28.93,20.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-01,NDC,outpatient,1,UN,5.45,3.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-11,NDC,outpatient,1,UN,5.45,3.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,00904-7119-06,NDC,outpatient,1,UN,3.29,2.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-60,NDC,outpatient,1,UN,29.34,20.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-01,NDC,outpatient,1,UN,29.34,20.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-01,NDC,outpatient,1,UN,46.07,32.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-60,NDC,outpatient,1,UN,46.07,32.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-60,NDC,outpatient,1,UN,70.24,49.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-01,NDC,outpatient,1,UN,70.24,49.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-60,NDC,outpatient,1,UN,72.31,50.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-01,NDC,outpatient,1,UN,72.31,50.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRENATAL VITAMIN PLUS LOW IRON 27-1 MG ORAL TABS,RX-133380,CDM,S5000,HCPCS,259,RC,39328-0106-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMCICLOVIR 500 MG ORAL TABS,RX-13358,CDM,S5000,HCPCS,259,RC,60505-3247-03,NDC,outpatient,1,UN,1.93,1.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,14.6,10.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,14.6,10.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-27,NDC,outpatient,3,ML,1168.7,818.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-01,NDC,outpatient,3,ML,1168.7,818.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EMTRICITABINE-TENOFOVIR AF 200-25 MG ORAL TABS,RX-134420,CDM,S5000,HCPCS,259,RC,61958-2002-01,NDC,outpatient,1,UN,316.88,221.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70004-0540-35,NDC,outpatient,125,ML,123.38,86.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1007-36,NDC,outpatient,125,ML,77.9,54.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1575-36,NDC,outpatient,125,ML,81.02,56.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PSYLLIUM 400 MG ORAL CAPS,RX-134482,CDM,S5000,HCPCS,259,RC,37000-0405-14,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,00904-3854-61,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-01,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-11,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE 100 MG/5ML ORAL SUSP,RX-1356,CDM,S5000,HCPCS,259,RC,99999-0001-92,NDC,outpatient,10,ML,6.06,4.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-01,NDC,outpatient,10,ML,411.18,287.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-05,NDC,outpatient,10,ML,411.18,287.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE 200 MG ORAL TABS,RX-1357,CDM,S5000,HCPCS,259,RC,00904-6172-61,NDC,outpatient,1,UN,2.42,1.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70004-0725-05,NDC,outpatient,1,ML,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,99999-0003-11,NDC,outpatient,1.1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70092-1443-43,NDC,outpatient,1,ML,22.08,15.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,99999-0001-84,NDC,outpatient,280,ML,33.42,23.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70004-0924-59,NDC,outpatient,280,ML,189.24,132.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70092-9056-05,NDC,outpatient,280,ML,121.34,84.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-21,NDC,outpatient,15,ML,17.89,12.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,00904-6627-35,NDC,outpatient,15,ML,6.35,4.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-23,NDC,outpatient,15,ML,15.56,10.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,00054-8550-25,NDC,outpatient,1,UN,5.49,3.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-15,NDC,outpatient,1,UN,5.12,3.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-11,NDC,outpatient,1,UN,5.12,3.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-136367,CDM,S5000,HCPCS,250,RC,44567-0601-04,NDC,outpatient,10,ML,205.59,143.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,11701-0067-23,NDC,outpatient,57,GR,25.88,18.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,53329-0172-10,NDC,outpatient,71,GR,15.17,10.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70092-9054-05,NDC,outpatient,275,ML,111.55,78.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,71506-0015-58,NDC,outpatient,275,ML,93.39,65.373,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,99999-0001-85,NDC,outpatient,275,ML,59.61,41.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70004-0923-59,NDC,outpatient,275,ML,170.02,119.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-00,NDC,outpatient,15,ML,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-15,NDC,outpatient,15,ML,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,99999-0003-40,NDC,outpatient,125,ML,51.6,36.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,76154-0818-05,NDC,outpatient,125,ML,82.75,57.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1068-07,NDC,outpatient,500,ML,106.3,74.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1552-07,NDC,outpatient,500,ML,97.53,68.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LINACLOTIDE 72 MCG ORAL CAPS,RX-138008,CDM,S5000,HCPCS,259,RC,00456-1203-30,NDC,outpatient,1,UN,74.11,51.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,00536-1263-28,NDC,outpatient,28,GR,4.99,3.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,57896-0145-14,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,58980-0011-10,NDC,outpatient,28.35,GR,10.1,7.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,71506-0019-59,NDC,outpatient,540,ML,128.46,89.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,99999-0002-01,NDC,outpatient,540,ML,36.84,25.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,99999-0002-00,NDC,outpatient,535,ML,35.39,24.773,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,71506-0017-59,NDC,outpatient,535,ML,119.16,83.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZOCAINE 20 % MT AERO,RX-138339,CDM,S5000,HCPCS,259,RC,00283-0679-02,NDC,outpatient,57,GR,120.74,84.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP,RX-138354,CDM,S5000,HCPCS,250,RC,10122-0510-01,NDC,outpatient,1.5,ML,1807.78,1265.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,RX-138355,CDM,S5000,HCPCS,250,RC,10122-0510-03,NDC,outpatient,3,ML,2153.49,1507.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-21,NDC,outpatient,1,UN,12.93,9.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00009-0450-03,NDC,outpatient,1,UN,9.24,6.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,59762-0450-01,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00115-5211-16,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-11,NDC,outpatient,1,UN,12.93,9.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1380-36,NDC,outpatient,100,ML,69.27,48.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,99999-0003-24,NDC,outpatient,100,ML,48.85,34.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1130-36,NDC,outpatient,100,ML,83.73,58.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,00310-6205-30,NDC,outpatient,1,UN,54.15,37.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,66993-0456-30,NDC,outpatient,1,UN,54.61,38.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,66993-0457-30,NDC,outpatient,1,UN,57.77,40.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,00310-6210-39,NDC,outpatient,1,UN,54.15,37.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,00536-5090-08,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,24208-0387-62,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-00,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARISOPRODOL 350 MG ORAL TABS,RX-1395,CDM,S5000,HCPCS,259,RC,50228-0109-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,51672-4130-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,00904-7007-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,51672-4131-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,00904-7008-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CARBONATE ANTACID 1250 MG/5ML ORAL SUSP,RX-140541,CDM,S5000,HCPCS,259,RC,00121-4766-05,NDC,outpatient,5,ML,9.19,6.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-01,NDC,outpatient,1,UN,13.61,9.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-20,NDC,outpatient,1,UN,13.61,9.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-20,NDC,outpatient,1,UN,16,11.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-01,NDC,outpatient,1,UN,16,11.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,S5000,HCPCS,259,RC,45802-0465-64,NDC,outpatient,120,ML,53.4,37.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,RX-141345,CDM,S5000,HCPCS,259,RC,59310-0302-40,NDC,outpatient,10.6,GR,878.5,614.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,RX-141346,CDM,S5000,HCPCS,259,RC,59310-0304-80,NDC,outpatient,10.6,GR,1176.28,823.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG ORAL TABS,RX-142007,CDM,S5000,HCPCS,259,RC,61958-2501-01,NDC,outpatient,1,UN,572.84,400.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,59762-5030-01,NDC,outpatient,35,ML,84.73,59.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,99999-0002-78,NDC,outpatient,5,ML,12.62,8.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,16714-0696-01,NDC,outpatient,35,ML,43.77,30.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,68585-0005-75,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,57896-0635-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,10006-0700-13,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,71740-0112-30,NDC,outpatient,0.25,ML,14.74,10.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,99999-0003-49,NDC,outpatient,1,ML,58.94,41.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG ORAL TABS,RX-143657,CDM,S5000,HCPCS,259,RC,59676-0800-30,NDC,outpatient,1,UN,678.69,475.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PIMAVANSERIN TARTRATE 34 MG ORAL CAPS,RX-143683,CDM,S5000,HCPCS,259,RC,63090-0340-30,NDC,outpatient,1,UN,740.93,518.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-39,NDC,outpatient,1,UN,69.73,48.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-01,NDC,outpatient,1,UN,69.73,48.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-99,NDC,outpatient,1,UN,58.96,41.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,52817-0610-04,NDC,outpatient,1,UN,36.6,25.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-16,NDC,outpatient,1,UN,58.96,41.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,82089-0102-34,NDC,outpatient,1,UN,502.38,351.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-04,NDC,outpatient,1,UN,89.34,62.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-01,NDC,outpatient,1,UN,43.76,30.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-54,NDC,outpatient,1,UN,89.34,62.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-04,NDC,outpatient,1,UN,43.76,30.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-04,NDC,outpatient,1,UN,122.13,85.491,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-54,NDC,outpatient,1,UN,122.13,85.491,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,42571-0141-26,NDC,outpatient,10,ML,151.26,105.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,61314-0019-10,NDC,outpatient,10,ML,71.78,50.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,24208-0485-10,NDC,outpatient,10,ML,36.09,25.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-32,NDC,outpatient,3,ML,93.63,65.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-93,NDC,outpatient,3,ML,93.63,65.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-11,NDC,outpatient,1,UN,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-15,NDC,outpatient,1,UN,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-11,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-15,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-02,NDC,outpatient,5,ML,2091.2,1463.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-15,NDC,outpatient,5,ML,2091.2,1463.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,99999-0002-40,NDC,outpatient,5,ML,47,32.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,69238-1731-02,NDC,outpatient,473,ML,2201.68,1541.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL ER 180 MG ORAL TBCR,RX-14626,CDM,S5000,HCPCS,259,RC,75834-0158-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-21,NDC,outpatient,1,UN,9.29,6.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-11,NDC,outpatient,1,UN,9.29,6.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00093-0058-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00904-7179-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,29300-0355-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETIC ACID 5 % SOLN,RX-14702,CDM,S5000,HCPCS,259,RC,99999-0000-92,NDC,outpatient,60,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,00904-7163-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLYBURIDE MICRONIZED 1.5 MG ORAL TABS,RX-14777,CDM,S5000,HCPCS,259,RC,00093-8034-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147794,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-01,NDC,outpatient,100,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-03,NDC,outpatient,100,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-01,NDC,outpatient,1,UN,14.17,9.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-30,NDC,outpatient,1,UN,14.17,9.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-15,NDC,outpatient,1,UN,2.93,2.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-11,NDC,outpatient,1,UN,2.93,2.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIZANIDINE HCL 4 MG ORAL TABS,RX-14793,CDM,S5000,HCPCS,259,RC,00904-6418-61,NDC,outpatient,1,UN,1.85,1.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-77,NDC,outpatient,1,UN,20.73,14.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-32,NDC,outpatient,1,UN,22.99,16.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-88,NDC,outpatient,1,UN,22.99,16.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,64764-0544-11,NDC,outpatient,1,UN,56.9,39.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-30,NDC,outpatient,1,UN,20.73,14.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-01,NDC,outpatient,1,UN,1.75,1.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-11,NDC,outpatient,1,UN,1.75,1.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-11,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,00904-7048-61,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-15,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,69097-0579-67,NDC,outpatient,1,UN,204.35,143.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-94,NDC,outpatient,1,UN,214.58,150.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-99,NDC,outpatient,1,UN,214.58,150.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,70748-0299-01,NDC,outpatient,210,ML,615.84,431.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,99999-0004-54,NDC,outpatient,5,ML,14.67,10.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-01,NDC,outpatient,30,ML,8.02,5.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-03,NDC,outpatient,30,ML,8.02,5.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MOEXIPRIL HCL 7.5 MG ORAL TABS,RX-15025,CDM,S5000,HCPCS,259,RC,68462-0209-01,NDC,outpatient,1,UN,3.46,2.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0101-44,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,00904-2085-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0140-03,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORT-PRAMOXINE (PERIANAL) 2.5-1 % EX CREA,RX-150325,CDM,S5000,HCPCS,259,RC,45802-0472-64,NDC,outpatient,30,GR,583,408.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,99999-0001-49,NDC,outpatient,60,ML,11.75,8.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,51552-0051-06,NDC,outpatient,500,ML,97.9,68.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-62,NDC,outpatient,15,ML,10.55,7.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-59,NDC,outpatient,15,ML,10.55,7.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-01,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-20,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-11,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-01,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,99999-0001-69,NDC,outpatient,0.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,00087-0405-01,NDC,outpatient,0.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TACROLIMUS ER 1 MG ORAL TB24,RX-151676,CDM,S5000,HCPCS,259,RC,68992-3010-03,NDC,outpatient,1,UN,3.04,2.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TACROLIMUS ER 0.75 MG ORAL TB24,RX-151678,CDM,S5000,HCPCS,259,RC,68992-3075-03,NDC,outpatient,1,UN,2.28,1.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TACROLIMUS ER 4 MG ORAL TB24,RX-151679,CDM,S5000,HCPCS,259,RC,68992-3040-03,NDC,outpatient,1,UN,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-10,NDC,outpatient,10,ML,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-59,NDC,outpatient,10,ML,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-08,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,99999-0002-42,NDC,outpatient,10,ML,1.6,1.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-10,NDC,outpatient,10,ML,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-25,NDC,outpatient,1,ML,93.05,65.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-01,NDC,outpatient,1,ML,93.05,65.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHACHOLINE CHLORIDE IN KIT,RX-151916,CDM,S5000,HCPCS,259,RC,69374-0542-06,NDC,outpatient,18,ML,600.75,420.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,43598-0977-10,NDC,outpatient,100,GR,59.19,41.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,00536-1294-97,NDC,outpatient,100,GR,33.38,23.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,69097-0524-44,NDC,outpatient,100,GR,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUMATRIPTAN SUCCINATE 25 MG ORAL TABS,RX-15327,CDM,S5000,HCPCS,259,RC,65862-0146-36,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,61442-0102-01,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,00228-2550-11,NDC,outpatient,1,UN,1.63,1.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,16571-0202-10,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-01,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-11,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 75 MG ORAL TBEC,RX-15341,CDM,S5000,HCPCS,259,RC,16571-0201-06,NDC,outpatient,1,UN,1.46,1.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,05928-0000-99,NDC,outpatient,28.4,GR,22.75,15.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,00225-0525-47,NDC,outpatient,14.1,GR,10.92,7.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIMANTADINE HCL 100 MG ORAL TABS,RX-15440,CDM,S5000,HCPCS,259,RC,00115-1911-01,NDC,outpatient,1,UN,10.21,7.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHERRY ORAL SYRP,RX-1562,CDM,S5000,HCPCS,259,RC,00395-2662-16,NDC,outpatient,473,ML,78.58,55.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-09,NDC,outpatient,250,ML,59.39,41.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-13,NDC,outpatient,500,ML,73.85,51.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMANTADINE HCL 50 MG/5ML ORAL SOLN,RX-156382,CDM,S5000,HCPCS,259,RC,00121-0646-10,NDC,outpatient,10,ML,13.67,9.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALENDRONATE SODIUM 10 MG ORAL TABS,RX-15661,CDM,S5000,HCPCS,259,RC,16714-0631-01,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156724,CDM,S5000,HCPCS,250,RC,60267-0705-50,NDC,outpatient,50,ML,431.65,302.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN,RX-156740,CDM,S5000,HCPCS,250,RC,24571-0108-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN,RX-156741,CDM,S5000,HCPCS,250,RC,24571-0105-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN,RX-156742,CDM,S5000,HCPCS,250,RC,24571-0102-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L EC SOLN,RX-156743,CDM,S5000,HCPCS,250,RC,24571-0103-06,NDC,outpatient,5000,ML,325.06,227.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,60505-0159-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,00093-1060-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,49884-0161-11,NDC,outpatient,3.7,ML,207.33,145.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,60505-0823-06,NDC,outpatient,3.7,ML,230.15,161.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARVEDILOL 6.25 MG ORAL TABS,RX-15747,CDM,S5000,HCPCS,259,RC,00904-6301-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,68382-0094-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,00904-6302-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,59762-3120-01,NDC,outpatient,18.75,ML,76.85,53.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,00093-2026-23,NDC,outpatient,18.75,ML,62.17,43.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,99999-0002-81,NDC,outpatient,6.25,ML,21.03,14.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DARUNAVIR 800 MG ORAL TABS,RX-158170,CDM,S5000,HCPCS,259,RC,59676-0566-30,NDC,outpatient,1,UN,310.53,217.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00002-7533-01,NDC,outpatient,3,ML,80.06,56.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5924-10,NDC,outpatient,10,ML,322.63,225.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5926-05,NDC,outpatient,3,ML,50.03,35.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,00904-6583-04,NDC,outpatient,1,UN,21.27,14.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,64380-0710-03,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LAMIVUDINE 10 MG/ML ORAL SOLN,RX-15881,CDM,S5000,HCPCS,259,RC,54838-0566-70,NDC,outpatient,15,ML,23.1,16.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACARBOSE 50 MG ORAL TABS,RX-15895,CDM,S5000,HCPCS,259,RC,64380-0759-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,S5000,HCPCS,259,RC,00436-0936-16,NDC,outpatient,473,ML,52.63,36.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-20,NDC,outpatient,1,UN,3544.84,2481.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-02,NDC,outpatient,1,UN,571.55,400.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-03,NDC,outpatient,1,UN,571.55,400.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-30,NDC,outpatient,1,UN,3544.84,2481.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,99999-0002-10,NDC,outpatient,10,ML,27.28,19.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,00406-0527-10,NDC,outpatient,0.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-160113,CDM,S5000,HCPCS,259,RC,00046-0872-21,NDC,outpatient,30,GR,1850.58,1295.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,S5000,HCPCS,259,RC,16714-0763-01,NDC,outpatient,60,GR,327.35,229.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,80681-0100-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-11,NDC,outpatient,1,UN,3.58,2.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-51,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,23155-0490-01,NDC,outpatient,1,UN,1.27,0.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-11,NDC,outpatient,1,UN,7.9,5.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-21,NDC,outpatient,1,UN,7.9,5.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLENE BLUE 1 % IV SOLN,RX-160649,CDM,S5000,HCPCS,250,RC,54288-0147-01,NDC,outpatient,10,ML,616.77,431.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,00574-0520-74,NDC,outpatient,120,ML,51.8,36.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,66689-0203-04,NDC,outpatient,120,ML,73.16,51.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,24208-0398-30,NDC,outpatient,30,ML,45.66,31.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,00054-0045-44,NDC,outpatient,30,ML,160.2,112.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CARB-CHOLECALCIFEROL 600-5 MG-MCG ORAL TABS,RX-160700,CDM,S5000,HCPCS,259,RC,80681-0138-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,00054-0046-41,NDC,outpatient,15,ML,147.99,103.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,60505-0827-01,NDC,outpatient,15,ML,69.49,48.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMCICLOVIR 250 MG ORAL TABS,RX-16081,CDM,S5000,HCPCS,259,RC,60505-3246-03,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-03,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,00536-3223-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RILUZOLE 50 MG ORAL TABS,RX-16124,CDM,S5000,HCPCS,259,RC,67877-0286-60,NDC,outpatient,1,UN,2.96,2.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,00054-3120-41,NDC,outpatient,1,ML,24.45,17.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,63304-0241-59,NDC,outpatient,1,ML,19.3,13.51,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,99999-0002-71,NDC,outpatient,1,ML,19.3,13.51,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-20,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,00555-0159-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-01,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-01,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-20,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EUCERIN ORIGINAL HEALING EX CREA,RX-162713,CDM,S5000,HCPCS,259,RC,72140-0038-68,NDC,outpatient,57,GR,20.04,14.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-11,NDC,outpatient,1,UN,2.06,1.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,55111-0321-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-01,NDC,outpatient,1,UN,2.06,1.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPH-SHARK LIV OIL-MO-PET 0.25-3-14-71.9 % RE OINT,RX-16462,CDM,S5000,HCPCS,259,RC,00573-2871-93,NDC,outpatient,28,GR,25.8,18.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,00904-7129-61,NDC,outpatient,1,UN,10.41,7.287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-15,NDC,outpatient,1,UN,4.66,3.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-11,NDC,outpatient,1,UN,4.66,3.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,69238-1060-01,NDC,outpatient,1,UN,6.98,4.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,00904-7132-61,NDC,outpatient,1,UN,20.86,14.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-11,NDC,outpatient,1,UN,7.19,5.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-15,NDC,outpatient,1,UN,7.19,5.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,69238-1056-01,NDC,outpatient,1,UN,2.88,2.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00065-4011-05,NDC,outpatient,5,ML,42.77,29.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00536-1252-40,NDC,outpatient,5,ML,30.09,21.063,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,72485-0617-10,NDC,outpatient,5,ML,28.93,20.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-20,NDC,outpatient,1,UN,7.86,5.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-01,NDC,outpatient,1,UN,7.86,5.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-01,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-11,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,63739-0888-10,NDC,outpatient,1,UN,2.7,1.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERROUS SULFATE ER 45 MG ORAL TBCR,RX-167735,CDM,S5000,HCPCS,259,RC,10006-0730-13,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,S5000,HCPCS,250,RC,00942-0641-04,NDC,outpatient,1000,ML,60.15,42.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,20555-0036-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYOSCYAMINE SULFATE ER 0.375 MG ORAL TB12,RX-17010,CDM,S5000,HCPCS,259,RC,51525-0115-01,NDC,outpatient,1,UN,1.16,0.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANDOLAPRIL 1 MG ORAL TABS,RX-17017,CDM,S5000,HCPCS,259,RC,68180-0566-01,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SELEGILINE HCL 5 MG ORAL CAPS,RX-17280,CDM,S5000,HCPCS,259,RC,60505-0055-01,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0452-31,NDC,outpatient,50,GR,20.25,14.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,61924-0184-04,NDC,outpatient,106,GR,13.68,9.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0031-47,NDC,outpatient,396,GR,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,65162-0673-84,NDC,outpatient,0.25,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,27808-0002-01,NDC,outpatient,0.25,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,99999-0003-81,NDC,outpatient,1,ML,4.12,2.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AZITHROMYCIN 600 MG ORAL TABS,RX-17387,CDM,S5000,HCPCS,259,RC,62332-0253-30,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN HCL 150 MG ORAL CAPS,RX-1740,CDM,S5000,HCPCS,259,RC,00904-5959-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEVIRAPINE 200 MG ORAL TABS,RX-17403,CDM,S5000,HCPCS,259,RC,31722-0505-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,00168-0201-60,NDC,outpatient,60,ML,139.11,97.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,45802-0562-02,NDC,outpatient,60,ML,48.6,34.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,00904-6519-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,RX-17524,CDM,S5000,HCPCS,250,RC,59584-0138-01,NDC,outpatient,0.1,ML,121.71,85.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-01,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-11,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABS,RX-1759,CDM,S5000,HCPCS,259,RC,13107-0319-01,NDC,outpatient,1,UN,4.43,3.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,45802-0434-11,NDC,outpatient,30,GR,10.42,7.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,51672-2002-02,NDC,outpatient,30,GR,6.01,4.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,S5000,HCPCS,259,RC,51672-1260-03,NDC,outpatient,30,ML,97.86,68.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,S5000,HCPCS,259,RC,51672-2003-06,NDC,outpatient,45,GR,11.82,8.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,70069-0231-01,NDC,outpatient,5,ML,7.26,5.082,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,61314-0143-05,NDC,outpatient,5,ML,13.04,9.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,24208-0411-05,NDC,outpatient,5,ML,61.95,43.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,71921-0185-05,NDC,outpatient,5,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
B COMPLEX ORAL CAPS,RX-17882,CDM,S5000,HCPCS,259,RC,54629-0560-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 5 MG ORAL TABS,RX-17936,CDM,S5000,HCPCS,259,RC,00904-6377-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXAMETHASONE 1 MG/ML ORAL CONC,RX-17946,CDM,S5000,HCPCS,259,RC,00054-3176-44,NDC,outpatient,30,ML,90.92,63.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-21,NDC,outpatient,1,UN,10.83,7.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-11,NDC,outpatient,1,UN,10.83,7.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,S5000,HCPCS,259,RC,45802-0513-77,NDC,outpatient,140,GR,35.52,24.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CODEINE SULFATE 15 MG ORAL TABS,RX-1801,CDM,S5000,HCPCS,259,RC,00054-0243-24,NDC,outpatient,1,UN,2.94,2.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNA 8.6 MG ORAL TABS,RX-18138,CDM,S5000,HCPCS,259,RC,00904-7252-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-01,NDC,outpatient,1,UN,13.56,9.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-03,NDC,outpatient,1,UN,13.56,9.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,65162-0710-09,NDC,outpatient,1,UN,2.83,1.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISOPROLOL FUMARATE 5 MG ORAL TABS,RX-18288,CDM,S5000,HCPCS,259,RC,29300-0126-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,10135-0742-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,29300-0189-01,NDC,outpatient,1,UN,2.16,1.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG ORAL TABS,RX-18290,CDM,S5000,HCPCS,259,RC,29300-0188-01,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,68462-0878-30,NDC,outpatient,1,UN,1.61,1.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,29300-0187-01,NDC,outpatient,1,UN,2.03,1.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-11,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-15,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-29,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-01,NDC,outpatient,1,UN,1.28,0.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-25,NDC,outpatient,1,UN,1.1,0.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-11,NDC,outpatient,1,UN,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-11,NDC,outpatient,1,UN,1.28,0.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-15,NDC,outpatient,1,UN,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,31722-0532-01,NDC,outpatient,1,UN,2.32,1.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-15,NDC,outpatient,1,UN,1.64,1.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-11,NDC,outpatient,1,UN,1.64,1.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,00904-6667-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,63739-0904-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,45963-0556-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,63739-0903-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,16714-0662-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,00904-6666-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,00904-6665-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,63739-0902-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 2 MG ORAL TABS,RX-18311,CDM,S5000,HCPCS,259,RC,00904-7363-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,00904-7362-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,42291-0910-60,NDC,outpatient,1,UN,11.7,8.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-01,NDC,outpatient,1,UN,2.72,1.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-11,NDC,outpatient,1,UN,2.72,1.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-95,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-25,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-01,NDC,outpatient,1,UN,164.07,114.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-01,NDC,outpatient,1,UN,164.48,115.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-10,NDC,outpatient,1,UN,164.07,114.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-03,NDC,outpatient,1,UN,164.48,115.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARVEDILOL 3.125 MG ORAL TABS,RX-18551,CDM,S5000,HCPCS,259,RC,00904-6300-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,59762-0333-02,NDC,outpatient,2.5,ML,18.92,13.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,70069-0421-01,NDC,outpatient,2.5,ML,19.9,13.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,24208-0463-25,NDC,outpatient,2.5,ML,46.77,32.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,61314-0547-01,NDC,outpatient,2.5,ML,19.1,13.37,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DONEPEZIL HCL 5 MG ORAL TABS,RX-18786,CDM,S5000,HCPCS,259,RC,00904-6477-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,43598-0587-23,NDC,outpatient,2,ML,87.58,61.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,67457-0839-02,NDC,outpatient,2,ML,53.45,37.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,72485-0105-01,NDC,outpatient,2,ML,69.91,48.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOFLOXACIN 250 MG ORAL TABS,RX-18918,CDM,S5000,HCPCS,259,RC,00904-6351-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOFLOXACIN 500 MG ORAL TABS,RX-18919,CDM,S5000,HCPCS,259,RC,00904-6352-61,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-11,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-01,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-01,NDC,outpatient,1,UN,2.19,1.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-11,NDC,outpatient,1,UN,2.19,1.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATORVASTATIN CALCIUM 10 MG ORAL TABS,RX-19176,CDM,S5000,HCPCS,259,RC,00904-6290-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATORVASTATIN CALCIUM 20 MG ORAL TABS,RX-19178,CDM,S5000,HCPCS,259,RC,00904-6291-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,S5000,HCPCS,259,RC,60505-0833-05,NDC,outpatient,30,ML,24.97,17.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,23155-0823-73,NDC,outpatient,1,UN,8.36,5.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,50742-0118-08,NDC,outpatient,1,UN,13.91,9.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,59762-1005-01,NDC,outpatient,1,UN,22.17,15.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,S5000,HCPCS,259,RC,70756-0614-30,NDC,outpatient,5,ML,178,124.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZOCAINE 20 % MT GEL,RX-19691,CDM,S5000,HCPCS,259,RC,10310-0566-20,NDC,outpatient,11.9,GR,20.34,14.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,S5000,HCPCS,259,RC,00065-0023-15,NDC,outpatient,1.5,ML,66,46.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,00254-1010-19,NDC,outpatient,30,ML,1132.89,793.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,99999-0003-50,NDC,outpatient,1,ML,37.77,26.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,24208-0457-05,NDC,outpatient,5,ML,46.46,32.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,61314-0014-25,NDC,outpatient,2.5,ML,39.79,27.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,S5000,HCPCS,259,RC,11980-0228-05,NDC,outpatient,5,ML,692.51,484.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00009-0746-30,NDC,outpatient,1,ML,216.41,151.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00548-5400-00,NDC,outpatient,1,ML,75.65,52.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,00135-0199-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,49348-0541-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,60505-0560-00,NDC,outpatient,5,ML,32.22,22.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,64980-0515-05,NDC,outpatient,5,ML,58.61,41.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POVIDONE-IODINE 5 % OP SOLN,RX-19791,CDM,S5000,HCPCS,259,RC,00065-0411-30,NDC,outpatient,30,ML,45.26,31.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-POLYMYXIN-PRAMOXINE 1 % EX CREA,RX-19880,CDM,S5000,HCPCS,259,RC,12547-0407-40,NDC,outpatient,14.2,GR,19.03,13.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-01,NDC,outpatient,1,UN,1.26,0.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-11,NDC,outpatient,1,UN,1.26,0.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NELFINAVIR MESYLATE 250 MG ORAL TABS,RX-20032,CDM,S5000,HCPCS,259,RC,63010-0010-30,NDC,outpatient,1,UN,17.47,12.229,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESNA 400 MG ORAL TABS,RX-20077,CDM,S5000,HCPCS,259,RC,67108-3565-09,NDC,outpatient,1,UN,287.17,201.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-06,NDC,outpatient,15,ML,121.82,85.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-01,NDC,outpatient,2,ML,47.31,33.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-15,NDC,outpatient,1,UN,2.94,2.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-11,NDC,outpatient,1,UN,2.94,2.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-03,NDC,outpatient,10,ML,375.94,263.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-01,NDC,outpatient,10,ML,375.94,263.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,00172-5241-60,NDC,outpatient,1,UN,3.43,2.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,13668-0453-01,NDC,outpatient,1,UN,2.97,2.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-01,NDC,outpatient,10,ML,25.46,17.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-10,NDC,outpatient,20,ML,27.51,19.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,55150-0221-10,NDC,outpatient,10,ML,12.44,8.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-01,NDC,outpatient,20,ML,27.51,19.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-10,NDC,outpatient,10,ML,13.73,9.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-10,NDC,outpatient,10,ML,25.46,17.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-01,NDC,outpatient,10,ML,13.73,9.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX LIQD,RX-20781,CDM,S5000,HCPCS,259,RC,49348-0443-34,NDC,outpatient,118,ML,21.53,15.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIGLITOL 25 MG ORAL TABS,RX-20799,CDM,S5000,HCPCS,259,RC,69367-0303-01,NDC,outpatient,1,UN,7.35,5.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-41,NDC,outpatient,5,ML,10.16,7.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-01,NDC,outpatient,5,ML,9.31,6.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-05,NDC,outpatient,5,ML,9.31,6.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-05,NDC,outpatient,5,ML,10.16,7.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-01,NDC,outpatient,5,ML,20.56,14.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-10,NDC,outpatient,5,ML,20.56,14.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-11,NDC,outpatient,1,UN,3.5,2.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,65862-0641-63,NDC,outpatient,1,UN,1.45,1.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-01,NDC,outpatient,1,UN,3.5,2.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-10,NDC,outpatient,5,ML,94.7,66.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,54482-0147-01,NDC,outpatient,5,ML,99.51,69.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-01,NDC,outpatient,5,ML,94.7,66.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 2.5 MG ORAL TABS,RX-21057,CDM,S5000,HCPCS,259,RC,00904-6283-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-01,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-11,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,62756-0184-88,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CITALOPRAM HYDROBROMIDE 20 MG ORAL TABS,RX-21062,CDM,S5000,HCPCS,259,RC,00904-6085-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG ORAL TABS,RX-21284,CDM,S5000,HCPCS,259,RC,42806-0339-01,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-11,NDC,outpatient,1,UN,3.34,2.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-21,NDC,outpatient,1,UN,3.34,2.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG ORAL TABS,RX-21289,CDM,S5000,HCPCS,259,RC,68462-0334-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG ORAL TABS,RX-21290,CDM,S5000,HCPCS,259,RC,00904-6704-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,60505-0033-06,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,00904-5448-61,NDC,outpatient,1,UN,1.11,0.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAPSONE 100 MG ORAL TABS,RX-2131,CDM,S5000,HCPCS,259,RC,70954-0136-10,NDC,outpatient,1,UN,5.05,3.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAPSONE 25 MG ORAL TABS,RX-2132,CDM,S5000,HCPCS,259,RC,70954-0135-10,NDC,outpatient,1,UN,4.35,3.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,00078-0249-15,NDC,outpatient,1,UN,108.93,76.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,59651-0180-30,NDC,outpatient,1,UN,1.55,1.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR,RX-21672,CDM,S5000,HCPCS,250,RC,24338-0050-08,NDC,outpatient,8,UN,110831.48,77582.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROPINIROLE HCL 0.25 MG ORAL TABS,RX-21688,CDM,S5000,HCPCS,259,RC,00904-6373-61,NDC,outpatient,1,UN,1.51,1.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROPINIROLE HCL 1 MG ORAL TABS,RX-21689,CDM,S5000,HCPCS,259,RC,00904-6374-61,NDC,outpatient,1,UN,1.76,1.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-15,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-11,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,00904-6638-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
QUETIAPINE FUMARATE 100 MG ORAL TABS,RX-21824,CDM,S5000,HCPCS,259,RC,00904-6640-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TIAGABINE HCL 4 MG ORAL TABS,RX-21827,CDM,S5000,HCPCS,259,RC,62756-0224-83,NDC,outpatient,1,UN,16.11,11.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,31722-0730-90,NDC,outpatient,1,UN,1.91,1.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,33342-0048-10,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOPIDOGREL BISULFATE 75 MG ORAL TABS,RX-22142,CDM,S5000,HCPCS,259,RC,00904-6294-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-11,NDC,outpatient,1,UN,23.4,16.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-21,NDC,outpatient,1,UN,23.4,16.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-13,NDC,outpatient,1,UN,40.12,28.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-03,NDC,outpatient,1,UN,40.12,28.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-04,NDC,outpatient,5,ML,27.71,19.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-56,NDC,outpatient,5,ML,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-56,NDC,outpatient,5,ML,27.71,19.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-44,NDC,outpatient,5,ML,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,51672-1370-01,NDC,outpatient,15,GR,62.62,43.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,68462-0564-17,NDC,outpatient,15,GR,861.28,602.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,24208-0410-05,NDC,outpatient,5,ML,214.49,150.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,70756-0609-15,NDC,outpatient,5,ML,31.29,21.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,00904-5224-52,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-50,NDC,outpatient,1,UN,1.55,1.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-25,NDC,outpatient,1,UN,1.55,1.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-06,NDC,outpatient,1,UN,1.19,0.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-61,NDC,outpatient,1,UN,1.44,1.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-15,NDC,outpatient,1,UN,2.8,1.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-11,NDC,outpatient,1,UN,2.8,1.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-40,NDC,outpatient,20,ML,60.61,42.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,99999-0002-45,NDC,outpatient,20,ML,22.52,15.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-20,NDC,outpatient,20,ML,60.61,42.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
REPAGLINIDE 2 MG ORAL TABS,RX-22585,CDM,S5000,HCPCS,259,RC,65862-0672-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
REPAGLINIDE 1 MG ORAL TABS,RX-22586,CDM,S5000,HCPCS,259,RC,65862-0671-01,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,00121-0676-16,NDC,outpatient,15,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,60258-0003-16,NDC,outpatient,10,ML,5.88,4.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,99999-0002-34,NDC,outpatient,15,ML,3.14,2.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,00904-6890-04,NDC,outpatient,1,UN,10.99,7.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,68462-0473-01,NDC,outpatient,1,UN,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-11,NDC,outpatient,1,UN,6.99,4.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-21,NDC,outpatient,1,UN,6.99,4.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESIPRAMINE HCL 25 MG ORAL TABS,RX-2286,CDM,S5000,HCPCS,259,RC,50742-0113-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,70954-0319-10,NDC,outpatient,5,ML,32.69,22.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,99999-0001-34,NDC,outpatient,10,ML,72.98,51.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,70069-0051-01,NDC,outpatient,10,ML,38.99,27.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,24208-0486-10,NDC,outpatient,10,ML,45.62,31.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,65862-0946-01,NDC,outpatient,10,ML,89,62.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,71921-0226-10,NDC,outpatient,10,ML,45.39,31.773,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,82584-0605-10,NDC,outpatient,10,ML,996.05,697.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,00781-1874-31,NDC,outpatient,1,UN,6.58,4.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,42571-0160-30,NDC,outpatient,1,UN,9.65,6.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,00004-1101-50,NDC,outpatient,1,UN,195.05,136.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,16729-0073-29,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISEDRONATE SODIUM 30 MG ORAL TABS,RX-23015,CDM,S5000,HCPCS,259,RC,00093-3100-56,NDC,outpatient,1,UN,220.55,154.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,00536-1268-12,NDC,outpatient,222,ML,16.8,11.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,46122-0573-10,NDC,outpatient,222,ML,11.13,7.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINISOL SF 15 % IV SOLN,RX-23068,CDM,S5000,HCPCS,250,RC,00338-0502-06,NDC,outpatient,2000,ML,211.8,148.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1147-03,NDC,outpatient,1000,ML,122.8,85.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1123-04,NDC,outpatient,2000,ML,211.8,148.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXAMETHASONE 0.5 MG ORAL TABS,RX-2322,CDM,S5000,HCPCS,259,RC,00054-8179-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,62332-0341-90,NDC,outpatient,1,UN,4.08,2.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,33342-0114-07,NDC,outpatient,1,UN,5.64,3.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CANDESARTAN CILEXETIL 16 MG ORAL TABS,RX-23231,CDM,S5000,HCPCS,259,RC,33342-0116-07,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXAMETHASONE 1 MG ORAL TABS,RX-2324,CDM,S5000,HCPCS,259,RC,00054-8174-25,NDC,outpatient,1,UN,1.46,1.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,00054-8175-25,NDC,outpatient,1,UN,4.2,2.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-51,NDC,outpatient,1,UN,4.47,3.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-80,NDC,outpatient,1,UN,4.47,3.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXAMETHASONE 6 MG ORAL TABS,RX-2328,CDM,S5000,HCPCS,259,RC,00054-8183-25,NDC,outpatient,1,UN,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,S5000,HCPCS,259,RC,24208-0720-02,NDC,outpatient,5,ML,228.82,160.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,39328-0024-30,NDC,outpatient,30,GR,40.32,28.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-05,NDC,outpatient,5,GR,12.51,8.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-06,NDC,outpatient,5,GR,12.51,8.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-02,NDC,outpatient,250,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 20 % IV SOLN,RX-2359,CDM,S5000,HCPCS,250,RC,00990-7935-19,NDC,outpatient,500,ML,62.73,43.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,S5000,HCPCS,250,RC,00409-1775-10,NDC,outpatient,10,ML,57.77,40.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-16,NDC,outpatient,50,ML,31.82,22.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-34,NDC,outpatient,50,ML,59.41,41.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-16,NDC,outpatient,50,ML,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-66,NDC,outpatient,50,ML,58.08,40.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-02,NDC,outpatient,50,ML,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,76329-3302-01,NDC,outpatient,50,ML,66.31,46.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-64,NDC,outpatient,50,ML,59.41,41.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69374-0953-50,NDC,outpatient,50,ML,66.75,46.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69623-0201-39,NDC,outpatient,50,ML,93.45,65.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EFAVIRENZ 200 MG ORAL CAPS,RX-23900,CDM,S5000,HCPCS,259,RC,64980-0407-09,NDC,outpatient,1,UN,33.64,23.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,00172-3925-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MICONAZOLE NITRATE 4 % VA CREA,RX-24050,CDM,S5000,HCPCS,259,RC,63736-0442-01,NDC,outpatient,15,GR,44.73,31.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,00093-3123-01,NDC,outpatient,1,UN,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,59651-0565-01,NDC,outpatient,1,UN,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-59,NDC,outpatient,5,ML,21.65,15.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-62,NDC,outpatient,5,ML,21.65,15.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-11,NDC,outpatient,1,UN,1.75,1.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-01,NDC,outpatient,1,UN,1.75,1.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-01,NDC,outpatient,1,UN,1.8,1.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-11,NDC,outpatient,1,UN,1.8,1.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,63739-0432-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,00536-1248-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOSORBIDE MONONITRATE ER 60 MG ORAL TAB,RX-24268,CDM,S5000,HCPCS,259,RC,00904-6450-61,NDC,outpatient,1,UN,1.31,0.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TELMISARTAN 40 MG ORAL TABS,RX-24335,CDM,S5000,HCPCS,259,RC,00597-0040-37,NDC,outpatient,1,UN,19.23,13.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,S5000,HCPCS,259,RC,51672-3007-01,NDC,outpatient,10,ML,303.14,212.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-21,NDC,outpatient,1,UN,26.71,18.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,00378-4105-91,NDC,outpatient,1,UN,13.01,9.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-11,NDC,outpatient,1,UN,26.71,18.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIGOXIN 125 MCG ORAL TABS,RX-2444,CDM,S5000,HCPCS,259,RC,00904-5921-61,NDC,outpatient,1,UN,3.14,2.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-61,NDC,outpatient,1,UN,5.08,3.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-11,NDC,outpatient,1,UN,4.79,3.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-01,NDC,outpatient,1,UN,4.79,3.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-04,NDC,outpatient,1,UN,7.7,5.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,63739-0548-33,NDC,outpatient,1,UN,5.24,3.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-11,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-15,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-01,NDC,outpatient,1,UN,3.16,2.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,00904-6502-61,NDC,outpatient,1,UN,3.56,2.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-11,NDC,outpatient,1,UN,3.16,2.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,00904-6503-61,NDC,outpatient,1,UN,5.49,3.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,60505-3849-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOSORBIDE MONONITRATE ER 30 MG ORAL TB24,RX-24521,CDM,S5000,HCPCS,259,RC,00904-6449-61,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,00904-6791-04,NDC,outpatient,1,UN,21.38,14.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-11,NDC,outpatient,1,UN,25.83,18.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-11,NDC,outpatient,1,UN,21.38,14.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-21,NDC,outpatient,1,UN,21.38,14.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-12,NDC,outpatient,1,UN,25.83,18.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,S5000,HCPCS,259,RC,00574-7040-12,NDC,outpatient,1,UN,104.53,73.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-01,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,00093-0318-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-11,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIMENHYDRINATE 50 MG ORAL TABS,RX-2485,CDM,S5000,HCPCS,259,RC,00904-2051-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TACROLIMUS 0.5 MG ORAL CAPS,RX-24914,CDM,S5000,HCPCS,259,RC,00904-6623-61,NDC,outpatient,1,UN,2.82,1.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-56,NDC,outpatient,3,ML,7.12,4.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-45,NDC,outpatient,3,ML,7.12,4.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-01,NDC,outpatient,3,ML,5.32,3.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-11,NDC,outpatient,3,ML,5.32,3.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-01,NDC,outpatient,3,ML,5.47,3.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-11,NDC,outpatient,3,ML,5.47,3.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00487-9501-01,NDC,outpatient,3,ML,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-49,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-48,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-01,NDC,outpatient,3,ML,1.18,0.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-79,NDC,outpatient,3,ML,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-83,NDC,outpatient,3,ML,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-60,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-31,NDC,outpatient,3,ML,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-55,NDC,outpatient,3,ML,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-52,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,66689-0307-08,NDC,outpatient,160,ML,1111.44,778.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,99999-0002-21,NDC,outpatient,2.5,ML,69.2,48.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIPHENHYDRAMINE HCL 25 MG ORAL CAPS,RX-2509,CDM,S5000,HCPCS,259,RC,00904-7237-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-00,NDC,outpatient,5,ML,15.4,10.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-05,NDC,outpatient,5,ML,15.4,10.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,65862-0076-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,00143-9927-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,62135-0308-01,NDC,outpatient,1,UN,12.1,8.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,69315-0910-01,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,00406-1236-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,99999-0003-98,NDC,outpatient,5,ML,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,00472-0825-16,NDC,outpatient,5,ML,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,70752-0102-12,NDC,outpatient,5,ML,1.91,1.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIPYRIDAMOLE 25 MG ORAL TABS,RX-2528,CDM,S5000,HCPCS,259,RC,64980-0133-01,NDC,outpatient,1,UN,5.27,3.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-25,NDC,outpatient,1,UN,27.72,19.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-95,NDC,outpatient,1,UN,27.72,19.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DISOPYRAMIDE PHOSPHATE 100 MG ORAL CAPS,RX-2535,CDM,S5000,HCPCS,259,RC,00093-3127-01,NDC,outpatient,1,UN,5.28,3.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DISULFIRAM 250 MG ORAL TABS,RX-2540,CDM,S5000,HCPCS,259,RC,47781-0607-30,NDC,outpatient,1,UN,7.69,5.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-81,NDC,outpatient,1,UN,3.67,2.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-86,NDC,outpatient,1,UN,3.67,2.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-17,NDC,outpatient,1,UN,3.43,2.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-10,NDC,outpatient,1,UN,3.43,2.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-21,NDC,outpatient,1,UN,3.46,2.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-11,NDC,outpatient,1,UN,3.46,2.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68382-0112-14,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 0.5 MG ORAL TABS,RX-25520,CDM,S5000,HCPCS,259,RC,00904-7361-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-01,NDC,outpatient,1,UN,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-11,NDC,outpatient,1,UN,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-61,NDC,outpatient,1,UN,1.16,0.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-11,NDC,outpatient,1,UN,1.16,0.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,00904-6861-90,NDC,outpatient,1,UN,1.2,0.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-80,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7183-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,00006-0032-20,NDC,outpatient,1,UN,19.14,13.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,42799-0806-01,NDC,outpatient,1,UN,14.59,10.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,00904-7052-61,NDC,outpatient,1,UN,2.19,1.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-01,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-20,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-01,NDC,outpatient,1,UN,6.84,4.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-20,NDC,outpatient,1,UN,6.84,4.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,00378-6410-01,NDC,outpatient,1,UN,5.48,3.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-20,NDC,outpatient,1,UN,2.89,2.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,00378-3125-01,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-01,NDC,outpatient,1,UN,2.89,2.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,57896-0116-03,NDC,outpatient,85,GR,10.97,7.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1101-45,NDC,outpatient,85,GR,10.6,7.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1349-57,NDC,outpatient,85,GR,9.08,6.356,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-10,NDC,outpatient,1,UN,49.76,34.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-02,NDC,outpatient,1,UN,45.64,31.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-01,NDC,outpatient,1,UN,107.52,75.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-01,NDC,outpatient,1,UN,49.76,34.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-10,NDC,outpatient,1,UN,107.52,75.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-10,NDC,outpatient,1,UN,68.55,47.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-11,NDC,outpatient,1,UN,45.64,31.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-00,NDC,outpatient,1,UN,68.55,47.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-80,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,00904-6474-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-51,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00904-0430-06,NDC,outpatient,1,UN,5.29,3.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-11,NDC,outpatient,1,UN,4.84,3.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00143-2112-50,NDC,outpatient,1,UN,1.07,0.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-21,NDC,outpatient,1,UN,4.84,3.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-11,NDC,outpatient,1,UN,4.16,2.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-01,NDC,outpatient,1,UN,4.16,2.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,64380-0799-01,NDC,outpatient,1,UN,8.24,5.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,31722-0632-31,NDC,outpatient,1,UN,4.28,2.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,27241-0049-10,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-11,NDC,outpatient,1,UN,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-21,NDC,outpatient,1,UN,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EXEMESTANE 25 MG ORAL TABS,RX-26551,CDM,S5000,HCPCS,259,RC,59762-2858-01,NDC,outpatient,1,UN,6.65,4.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,65862-0246-08,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,00904-7124-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MOXIFLOXACIN HCL 400 MG ORAL TABS,RX-26854,CDM,S5000,HCPCS,259,RC,65862-0603-30,NDC,outpatient,1,UN,13.67,9.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,16729-0490-12,NDC,outpatient,1,UN,6.58,4.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,72205-0039-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,69452-0131-17,NDC,outpatient,1,UN,2.23,1.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,69452-0132-17,NDC,outpatient,1,UN,2.23,1.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,00904-6682-08,NDC,outpatient,1,UN,13.18,9.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,42291-0412-60,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,00904-6683-08,NDC,outpatient,1,UN,13.31,9.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,42291-0413-60,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TERBINAFINE HCL 1 % EX CREA,RX-27023,CDM,S5000,HCPCS,259,RC,51672-2080-01,NDC,outpatient,15,GR,24.57,17.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,S5000,HCPCS,259,RC,11980-0174-05,NDC,outpatient,5,ML,659.54,461.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-01,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-11,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHARCOAL ACTIVATED ORAL LIQD,RX-27099,CDM,S5000,HCPCS,259,RC,66689-0202-04,NDC,outpatient,120,ML,82.77,57.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISEDRONATE SODIUM 5 MG ORAL TABS,RX-27112,CDM,S5000,HCPCS,259,RC,33342-0107-07,NDC,outpatient,1,UN,11.13,7.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,47335-0539-81,NDC,outpatient,1,UN,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,59651-0018-90,NDC,outpatient,1,UN,1.7,1.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,49580-0394-04,NDC,outpatient,1814,GR,16.15,11.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-0038-01,NDC,outpatient,454,GR,8.09,5.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-1210-01,NDC,outpatient,454,GR,8.09,5.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-02,NDC,outpatient,2,ML,34.38,24.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-10,NDC,outpatient,10,ML,39.03,27.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE ER 100 MG ORAL CP24,RX-27418,CDM,S5000,HCPCS,259,RC,52244-0100-10,NDC,outpatient,1,UN,14.48,10.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,S5000,HCPCS,250,RC,63323-0113-10,NDC,outpatient,1,UN,686.14,480.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,S5000,HCPCS,259,RC,55566-2800-01,NDC,outpatient,1,UN,2100.63,1470.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-16,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-93,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-93,NDC,outpatient,1,UN,2.2,1.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-16,NDC,outpatient,1,UN,2.2,1.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-01,NDC,outpatient,1,UN,217.89,152.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-30,NDC,outpatient,1,UN,217.89,152.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-16,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-93,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,43598-0894-30,NDC,outpatient,1,UN,9.32,6.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-16,NDC,outpatient,1,UN,3.17,2.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-93,NDC,outpatient,1,UN,3.17,2.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,13668-0132-01,NDC,outpatient,1,UN,1.96,1.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,68462-0233-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,00603-3581-21,NDC,outpatient,1,UN,1.73,1.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,00536-1161-37,NDC,outpatient,1,UN,1.77,1.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,63824-0056-34,NDC,outpatient,1,UN,1.93,1.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-11,NDC,outpatient,1,UN,3.24,2.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68382-0106-01,NDC,outpatient,1,UN,1.55,1.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-01,NDC,outpatient,1,UN,3.24,2.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-13,NDC,outpatient,1,UN,7.06,4.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-11,NDC,outpatient,1,UN,7.06,4.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE ER 300 MG ORAL CP12,RX-27633,CDM,S5000,HCPCS,259,RC,66993-0409-32,NDC,outpatient,1,UN,5.66,3.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE ER 100 MG ORAL TB12,RX-27634,CDM,S5000,HCPCS,259,RC,51672-4123-01,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE ER 400 MG ORAL TB12,RX-27636,CDM,S5000,HCPCS,259,RC,51672-4125-01,NDC,outpatient,1,UN,2.24,1.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,49884-0007-02,NDC,outpatient,1,UN,22.19,15.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,68462-0405-60,NDC,outpatient,1,UN,2.36,1.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-11,NDC,outpatient,1,UN,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-01,NDC,outpatient,1,UN,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,62175-0262-37,NDC,outpatient,1,UN,9.51,6.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-21,NDC,outpatient,1,UN,11.24,7.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-11,NDC,outpatient,1,UN,11.24,7.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,S5000,HCPCS,259,RC,17238-0900-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,S5000,HCPCS,259,RC,41167-0057-24,NDC,outpatient,141,GR,30.75,21.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,RX-27770,CDM,S5000,HCPCS,259,RC,24208-0342-05,NDC,outpatient,5,ML,655.13,458.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-11,NDC,outpatient,1,UN,2.24,1.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-15,NDC,outpatient,1,UN,2.24,1.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,,,outpatient,500,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00409-7101-67,NDC,outpatient,100,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-38,NDC,outpatient,100,ML,22.17,15.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-41,NDC,outpatient,50,ML,22.94,16.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-48,NDC,outpatient,100,ML,22.69,15.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-02,NDC,outpatient,250,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-02,NDC,outpatient,250,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-04,NDC,outpatient,500,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00487-4301-10,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-11,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-01,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-01,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,00904-7077-61,NDC,outpatient,1,UN,1.54,1.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-11,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,S5000,HCPCS,259,RC,43598-0446-74,NDC,outpatient,1,UN,4.78,3.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,S5000,HCPCS,259,RC,43598-0447-74,NDC,outpatient,1,UN,5.28,3.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-33,NDC,outpatient,1,UN,7.5,5.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-74,NDC,outpatient,1,UN,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-88,NDC,outpatient,1,UN,7.5,5.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-28,NDC,outpatient,1,UN,5.25,3.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,62135-0712-42,NDC,outpatient,5,ML,20.16,14.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,00054-3500-49,NDC,outpatient,5,ML,2.23,1.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,72888-0125-26,NDC,outpatient,5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,99999-0002-05,NDC,outpatient,15,ML,60.48,42.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-47,NDC,outpatient,1,UN,17.49,12.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-11,NDC,outpatient,1,UN,17.49,12.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-16,NDC,outpatient,1,UN,37.78,26.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-98,NDC,outpatient,1,UN,37.78,26.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-11,NDC,outpatient,1,UN,25.49,17.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-47,NDC,outpatient,1,UN,25.49,17.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-47,NDC,outpatient,1,UN,37.66,26.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-11,NDC,outpatient,1,UN,37.66,26.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-16,NDC,outpatient,1,UN,93.74,65.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-98,NDC,outpatient,1,UN,93.74,65.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-30,NDC,outpatient,1,UN,4.71,3.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-10,NDC,outpatient,1,UN,3.99,2.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML ORAL SUSP,RX-27999,CDM,S5000,HCPCS,259,RC,46287-0006-60,NDC,outpatient,60,ML,91.85,64.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,16714-0601-02,NDC,outpatient,2.5,ML,10.37,7.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,99999-0003-51,NDC,outpatient,2.5,ML,10.37,7.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FE FUMARATE-B12-VIT C-FA-IFC ORAL CAPS,RX-28030,CDM,S5000,HCPCS,259,RC,51991-0635-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-01,NDC,outpatient,78,GR,22.91,16.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-02,NDC,outpatient,56,GR,17.7,12.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN BUF(CACARB-MGCARB-MGO) 325 MG ORAL TABS,RX-28122,CDM,S5000,HCPCS,259,RC,00904-2015-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-19,NDC,outpatient,1,UN,2.89,2.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-81,NDC,outpatient,1,UN,3.06,2.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-65,NDC,outpatient,1,UN,2.89,2.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,33342-0083-07,NDC,outpatient,1,UN,3.81,2.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-79,NDC,outpatient,1,UN,3.06,2.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,60505-3275-00,NDC,outpatient,1,UN,1.9,1.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-52,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-55,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,00904-6553-04,NDC,outpatient,1,UN,7.73,5.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-84,NDC,outpatient,1,UN,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-33,NDC,outpatient,1,UN,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,59762-1308-04,NDC,outpatient,150,ML,1694.12,1185.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,99999-0002-85,NDC,outpatient,30,ML,340.43,238.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,S5000,HCPCS,259,RC,63323-0877-15,NDC,outpatient,1,UN,686.24,480.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAPS,RX-28278,CDM,S5000,HCPCS,259,RC,00904-7107-61,NDC,outpatient,1,UN,10.27,7.189,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE TARTRATE 3 MG ORAL CAPS,RX-28279,CDM,S5000,HCPCS,259,RC,55111-0353-60,NDC,outpatient,1,UN,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN GLARGINE 100 UNIT/ML SC SOLN,RX-28282,CDM,S5000,HCPCS,259,RC,00088-2220-33,NDC,outpatient,10,ML,252.19,176.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-25,NDC,outpatient,1,UN,13.08,9.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-95,NDC,outpatient,1,UN,13.08,9.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-23,NDC,outpatient,1,UN,2,1.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-62,NDC,outpatient,1,UN,2,1.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-16,NDC,outpatient,1,UN,65.95,46.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-99,NDC,outpatient,1,UN,65.95,46.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-99,NDC,outpatient,1,UN,65.26,45.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-16,NDC,outpatient,1,UN,65.26,45.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-11,NDC,outpatient,1,UN,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-01,NDC,outpatient,1,UN,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,13811-0706-10,NDC,outpatient,1,UN,3.22,2.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,50458-0585-01,NDC,outpatient,1,UN,53.04,37.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00186-1988-04,NDC,outpatient,2,ML,35.8,25.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00487-9601-01,NDC,outpatient,2,ML,17.76,12.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-45,NDC,outpatient,2,ML,39.45,27.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-73,NDC,outpatient,2,ML,39.45,27.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00487-9701-01,NDC,outpatient,2,ML,14.93,10.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-05,NDC,outpatient,2,ML,5.21,3.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-30,NDC,outpatient,2,ML,5.21,3.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-53,NDC,outpatient,2,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-86,NDC,outpatient,2,ML,8.61,6.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-87,NDC,outpatient,2,ML,8.61,6.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,47335-0632-49,NDC,outpatient,1,ML,6.14,4.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-32,NDC,outpatient,2,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-21,NDC,outpatient,28.35,GR,7.2,5.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,38779-3068-00,NDC,outpatient,30,GR,75.03,52.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,53329-0993-04,NDC,outpatient,113,GR,5.26,3.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2311-00,NDC,outpatient,52.5,GR,7.25,5.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2335-00,NDC,outpatient,390,GR,19.1,13.37,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,08080-4302-01,NDC,outpatient,30,ML,5.88,4.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-16,NDC,outpatient,453.6,GR,58.59,41.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,61314-0645-11,NDC,outpatient,10,ML,217.88,152.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,24208-0635-62,NDC,outpatient,10,ML,221.08,154.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLYCERIN LIQD,RX-28815,CDM,S5000,HCPCS,259,RC,00395-1031-96,NDC,outpatient,177,ML,23.63,16.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP,RX-28836,CDM,S5000,HCPCS,259,RC,00121-0431-30,NDC,outpatient,30,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-19,NDC,outpatient,1,UN,1.84,1.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-65,NDC,outpatient,1,UN,1.84,1.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-61,NDC,outpatient,1,UN,46.19,32.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-15,NDC,outpatient,1,UN,46.19,32.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,RX-28844,CDM,S5000,HCPCS,259,RC,00172-7313-20,NDC,outpatient,50,ML,396.5,277.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN 2 % EX SOLN,RX-2887,CDM,S5000,HCPCS,259,RC,45802-0038-46,NDC,outpatient,60,ML,71.56,50.092,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,24208-0910-19,NDC,outpatient,1,GR,31.03,21.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-11,NDC,outpatient,1,GR,31.37,21.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-50,NDC,outpatient,1,GR,31.37,21.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,48102-0057-11,NDC,outpatient,1,GR,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-62,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-11,NDC,outpatient,1,UN,4.25,2.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-59,NDC,outpatient,1,UN,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-01,NDC,outpatient,1,UN,4.25,2.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-23,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-61,NDC,outpatient,1,UN,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,24338-0122-03,NDC,outpatient,1,UN,24.57,17.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,13668-0586-30,NDC,outpatient,1,UN,21.71,15.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NA HYALUR & NA CHOND-NA HYALUR 0.4-0.35 ML IO KIT,RX-28916,CDM,S5000,HCPCS,250,RC,08065-1831-35,NDC,outpatient,0.75,ML,867.31,607.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOFLOXACIN 750 MG ORAL TABS,RX-28964,CDM,S5000,HCPCS,259,RC,00904-6353-61,NDC,outpatient,1,UN,2.17,1.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,75834-0295-01,NDC,outpatient,100,ML,494.4,346.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,24338-0134-02,NDC,outpatient,100,ML,1005.7,703.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,99999-0002-77,NDC,outpatient,5,ML,50.87,35.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,70010-0491-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,51224-0007-50,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALENDRONATE SODIUM 70 MG ORAL TABS,RX-29048,CDM,S5000,HCPCS,259,RC,16714-0633-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALENDRONATE SODIUM 35 MG ORAL TABS,RX-29072,CDM,S5000,HCPCS,259,RC,16714-0632-01,NDC,outpatient,1,UN,5.43,3.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-40,NDC,outpatient,6,ML,15.62,10.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-06,NDC,outpatient,6,ML,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-90,NDC,outpatient,473,ML,168.39,117.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-16,NDC,outpatient,470,ML,144.32,101.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-07,NDC,outpatient,470,ML,154.78,108.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,99999-0003-42,NDC,outpatient,6,ML,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-06,NDC,outpatient,6,ML,15.62,10.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-06,NDC,outpatient,6,ML,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-01,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-11,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,68682-0993-98,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-30,NDC,outpatient,1,UN,1.44,1.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,00904-7218-61,NDC,outpatient,1,UN,1.28,0.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,62037-0598-90,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-11,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-01,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,00904-7219-61,NDC,outpatient,1,UN,1.59,1.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-11,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,24979-0029-07,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-11,NDC,outpatient,1,UN,6.23,4.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-01,NDC,outpatient,1,UN,6.23,4.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCOSANOL 10 % EX CREA,RX-29287,CDM,S5000,HCPCS,259,RC,00135-0300-01,NDC,outpatient,2,GR,72.76,50.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-11,NDC,outpatient,1,UN,5.8,4.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,72789-0149-69,NDC,outpatient,1,UN,1.89,1.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,00054-0079-28,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-13,NDC,outpatient,1,UN,5.8,4.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,65649-0101-02,NDC,outpatient,1,UN,26.86,18.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,60505-2575-07,NDC,outpatient,1,UN,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,16714-0496-01,NDC,outpatient,15,GR,55.61,38.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,00168-0258-15,NDC,outpatient,15,GR,71.29,49.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-21,NDC,outpatient,1,UN,7.98,5.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-11,NDC,outpatient,1,UN,7.98,5.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIRTAZAPINE 15 MG ORAL TBDP,RX-29531,CDM,S5000,HCPCS,259,RC,65862-0021-06,NDC,outpatient,1,UN,1.96,1.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIPRASIDONE HCL 20 MG ORAL CAPS,RX-29778,CDM,S5000,HCPCS,259,RC,00904-6269-08,NDC,outpatient,1,UN,11.99,8.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-12,NDC,outpatient,1,UN,7.96,5.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-09,NDC,outpatient,1,UN,7.81,5.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-11,NDC,outpatient,1,UN,7.81,5.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-11,NDC,outpatient,1,UN,7.96,5.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,00781-2168-60,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-09,NDC,outpatient,1,UN,7.81,5.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-11,NDC,outpatient,1,UN,7.81,5.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-11,NDC,outpatient,1,UN,14.03,9.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-21,NDC,outpatient,1,UN,14.03,9.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,70436-0004-06,NDC,outpatient,1,UN,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-61,NDC,outpatient,1,UN,2.19,1.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,45963-0709-11,NDC,outpatient,1,UN,1.28,0.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-01,NDC,outpatient,1,UN,2.11,1.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-20,NDC,outpatient,1,UN,2.11,1.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-06,NDC,outpatient,1,UN,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,50742-0615-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EYE STREAM OP SOLN,RX-2999,CDM,S5000,HCPCS,259,RC,00065-0530-01,NDC,outpatient,30,ML,81.97,57.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,50742-0616-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-01,NDC,outpatient,1,UN,1.9,1.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,68382-0565-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,00904-6323-61,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-20,NDC,outpatient,1,UN,1.9,1.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-11,NDC,outpatient,1,UN,2.35,1.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-01,NDC,outpatient,1,UN,5.81,4.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-03,NDC,outpatient,1,UN,5.81,4.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-11,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-15,NDC,outpatient,1,UN,2.35,1.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-01,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,00904-6324-61,NDC,outpatient,1,UN,2.66,1.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-25,NDC,outpatient,1,UN,121.31,84.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-95,NDC,outpatient,1,UN,121.31,84.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,63739-0357-33,NDC,outpatient,1,UN,93.6,65.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CITALOPRAM HYDROBROMIDE 10 MG ORAL TABS,RX-30264,CDM,S5000,HCPCS,259,RC,00904-6084-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-62,NDC,outpatient,5,ML,23.66,16.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-59,NDC,outpatient,5,ML,23.66,16.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,99999-0002-25,NDC,outpatient,5,ML,33.09,23.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,00078-0357-52,NDC,outpatient,5,ML,39.3,27.51,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MELATONIN 5 MG SL SUBL,RX-30511,CDM,S5000,HCPCS,259,RC,54629-0615-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7591-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7590-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,20555-0021-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,00904-7041-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-20,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,55111-0729-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,16714-0576-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-01,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-01,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,00904-6572-61,NDC,outpatient,1,UN,1.71,1.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-20,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,99999-0002-82,NDC,outpatient,5,ML,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,00143-9853-75,NDC,outpatient,75,ML,63.42,44.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-01,NDC,outpatient,1,UN,4.62,3.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,31722-0153-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,33342-0064-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-11,NDC,outpatient,1,UN,4.62,3.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,00574-9855-10,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,65162-0778-10,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,76204-0010-55,NDC,outpatient,3,ML,1.98,1.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,00487-0301-01,NDC,outpatient,3,ML,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-01,NDC,outpatient,3,ML,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-25,NDC,outpatient,3,ML,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,70010-0030-01,NDC,outpatient,1,UN,3.45,2.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,00228-3059-11,NDC,outpatient,1,UN,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,64850-0511-01,NDC,outpatient,1,UN,2,1.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,81542-0201-08,NDC,outpatient,226.8,GR,454.17,317.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,54295-0312-18,NDC,outpatient,226.8,GR,419.86,293.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TABS,RX-31684,CDM,S5000,HCPCS,259,RC,61958-0401-01,NDC,outpatient,1,UN,180.36,126.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,00093-0262-15,NDC,outpatient,15,GR,162.14,113.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,51672-1386-01,NDC,outpatient,15,GR,35.32,24.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,S5000,HCPCS,259,RC,51672-1264-01,NDC,outpatient,15,GR,55.01,38.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,S5000,HCPCS,259,RC,51672-1273-02,NDC,outpatient,20,ML,137.87,96.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,S5000,HCPCS,259,RC,60758-0880-05,NDC,outpatient,5,ML,308.83,216.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUPHENAZINE HCL 1 MG ORAL TABS,RX-3218,CDM,S5000,HCPCS,259,RC,00527-1788-01,NDC,outpatient,1,UN,6.6,4.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,70954-0274-10,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,00527-1789-01,NDC,outpatient,1,UN,10.2,7.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,69238-1680-01,NDC,outpatient,1,UN,6.45,4.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,00527-1790-01,NDC,outpatient,1,UN,13.8,9.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,39822-1100-01,NDC,outpatient,0.2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,63323-0184-10,NDC,outpatient,0.2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,00904-7224-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,65862-0676-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,00781-1061-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALPRAZOLAM 0.5 MG ORAL TABS,RX-325,CDM,S5000,HCPCS,259,RC,00781-1077-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAROXETINE HCL ER 12.5 MG ORAL TB24,RX-32631,CDM,S5000,HCPCS,259,RC,62175-0470-32,NDC,outpatient,1,UN,4.97,3.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPHENIDATE HCL ER (OSM) 27 MG ORAL TBCR,RX-32654,CDM,S5000,HCPCS,259,RC,13811-0707-10,NDC,outpatient,1,UN,3.33,2.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,00713-0861-30,NDC,outpatient,1,UN,39.98,27.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,68462-0437-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,33342-0179-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISEDRONATE SODIUM 35 MG ORAL TABS,RX-32895,CDM,S5000,HCPCS,259,RC,33342-0109-50,NDC,outpatient,1,UN,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-59,NDC,outpatient,4,ML,7.04,4.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-62,NDC,outpatient,4,ML,7.04,4.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-59,NDC,outpatient,5,ML,7.04,4.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-62,NDC,outpatient,5,ML,7.04,4.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00904-7177-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00054-8297-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,00054-8301-25,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMPHETAMINE-DEXTROAMPHET ER 5 MG ORAL CP24,RX-33005,CDM,S5000,HCPCS,259,RC,54092-0381-01,NDC,outpatient,1,UN,29.29,20.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VORICONAZOLE 200 MG ORAL TABS,RX-33009,CDM,S5000,HCPCS,259,RC,00904-7024-04,NDC,outpatient,1,UN,43.81,30.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TABS,RX-33227,CDM,S5000,HCPCS,259,RC,00781-1831-01,NDC,outpatient,1,UN,1.59,1.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,42571-0162-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,00143-9249-20,NDC,outpatient,1,UN,5.26,3.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-01,NDC,outpatient,1,UN,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-20,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,00904-6426-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-11,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-01,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-21,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,31722-0151-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-11,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-11,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-01,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METAXALONE 800 MG ORAL TABS,RX-33963,CDM,S5000,HCPCS,259,RC,00527-1435-01,NDC,outpatient,1,UN,2.54,1.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DUTASTERIDE 0.5 MG ORAL CAPS,RX-34089,CDM,S5000,HCPCS,259,RC,42806-0549-09,NDC,outpatient,1,UN,1.7,1.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-11,NDC,outpatient,1,UN,18.75,13.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,00904-7103-04,NDC,outpatient,1,UN,18.36,12.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,51660-0200-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-21,NDC,outpatient,1,UN,18.75,13.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,S5000,HCPCS,259,RC,45802-0056-35,NDC,outpatient,15,GR,170.02,119.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,S5000,HCPCS,259,RC,45802-0046-35,NDC,outpatient,15,GR,132.44,92.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,24208-0580-60,NDC,outpatient,5,ML,23.41,16.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,61314-0633-05,NDC,outpatient,5,ML,21.99,15.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-01,NDC,outpatient,1,UN,22.5,15.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-11,NDC,outpatient,1,UN,22.5,15.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-11,NDC,outpatient,1,UN,27.24,19.068,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-21,NDC,outpatient,1,UN,27.24,19.068,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,27241-0054-03,NDC,outpatient,1,UN,2.88,2.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,63739-0078-33,NDC,outpatient,1,UN,22.38,15.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-01,NDC,outpatient,1,UN,2.75,1.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-11,NDC,outpatient,1,UN,2.75,1.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,35573-0415-30,NDC,outpatient,1,UN,14,9.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,55111-0519-30,NDC,outpatient,1,UN,7.25,5.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,68462-0265-30,NDC,outpatient,1,UN,4.5,3.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,31722-0714-30,NDC,outpatient,1,UN,8.16,5.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,16714-0757-01,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,64980-0375-03,NDC,outpatient,1,UN,7.25,5.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-95,NDC,outpatient,1,UN,14.68,10.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,68462-0268-30,NDC,outpatient,1,UN,2.91,2.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,00093-3545-56,NDC,outpatient,1,UN,17.9,12.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-25,NDC,outpatient,1,UN,14.68,10.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-23,NDC,outpatient,1,UN,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-62,NDC,outpatient,1,UN,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-11,NDC,outpatient,1,UN,6.96,4.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-21,NDC,outpatient,1,UN,6.96,4.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-11,NDC,outpatient,1,UN,11.98,8.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-21,NDC,outpatient,1,UN,11.98,8.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,42858-0502-03,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,00054-0188-13,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,65162-0416-03,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,42858-0602-03,NDC,outpatient,1,UN,27,18.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-11,NDC,outpatient,1,UN,14.96,10.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-15,NDC,outpatient,1,UN,14.96,10.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,24208-0631-10,NDC,outpatient,10,ML,205.06,143.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,61314-0646-10,NDC,outpatient,10,ML,188.28,131.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,00904-6779-61,NDC,outpatient,1,UN,3.97,2.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-01,NDC,outpatient,1,UN,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-11,NDC,outpatient,1,UN,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-01,NDC,outpatient,1,UN,5.36,3.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-11,NDC,outpatient,1,UN,5.36,3.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-11,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-15,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,16714-0990-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,00904-6780-61,NDC,outpatient,1,UN,3.57,2.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,S5000,HCPCS,259,RC,00023-9163-30,NDC,outpatient,1,UN,44.22,30.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,00536-0091-85,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,99999-0002-48,NDC,outpatient,30,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GRISEOFULVIN ULTRAMICROSIZE 250 MG ORAL TABS,RX-3536,CDM,S5000,HCPCS,259,RC,00115-1725-01,NDC,outpatient,1,UN,20.98,14.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-01,NDC,outpatient,1,UN,10.21,7.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-08,NDC,outpatient,1,UN,349.43,244.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-01,NDC,outpatient,1,UN,349.43,244.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-08,NDC,outpatient,1,UN,10.21,7.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-52,NDC,outpatient,1,UN,2.41,1.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-55,NDC,outpatient,1,UN,2.41,1.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-52,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-55,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,72266-0158-01,NDC,outpatient,3,ML,45.03,31.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,00832-1410-03,NDC,outpatient,3,ML,113.88,79.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,62756-0143-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,67877-0414-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,70010-0492-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00378-0214-01,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00832-1530-11,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-20,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-01,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,99999-0003-09,NDC,outpatient,0.5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,54838-0501-15,NDC,outpatient,0.5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-01,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,63739-0972-10,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-89,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00832-5325-11,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-01,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-89,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATAZANAVIR SULFATE 150 MG ORAL CAPS,RX-36149,CDM,S5000,HCPCS,259,RC,42385-0920-60,NDC,outpatient,1,UN,11.33,7.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATAZANAVIR SULFATE 200 MG ORAL CAPS,RX-36150,CDM,S5000,HCPCS,259,RC,65862-0712-60,NDC,outpatient,1,UN,13.22,9.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREMASOL 10 % IV SOLN,RX-36160,CDM,S5000,HCPCS,250,RC,00338-1130-03,NDC,outpatient,500,ML,98.33,68.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EMTRICITABINE 200 MG ORAL CAPS,RX-36252,CDM,S5000,HCPCS,259,RC,61958-0601-01,NDC,outpatient,1,UN,77.2,54.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-15,NDC,outpatient,1,UN,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-11,NDC,outpatient,1,UN,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-01,NDC,outpatient,1,UN,15.64,10.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-11,NDC,outpatient,1,UN,15.64,10.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,62756-0427-90,NDC,outpatient,7.5,ML,336.96,235.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,16714-0628-01,NDC,outpatient,7.5,ML,422.83,295.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,43598-0326-75,NDC,outpatient,7.5,ML,438.69,307.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-05,NDC,outpatient,5,ML,9.93,6.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-40,NDC,outpatient,5,ML,12.02,8.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-67,NDC,outpatient,5,ML,12.02,8.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-40,NDC,outpatient,5,ML,9.93,6.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROSUVASTATIN CALCIUM 5 MG ORAL TABS,RX-36612,CDM,S5000,HCPCS,259,RC,00904-6778-61,NDC,outpatient,1,UN,2.9,2.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETOROLAC TROMETHAMINE 0.4 % OP SOLN,RX-36631,CDM,S5000,HCPCS,259,RC,60758-0773-05,NDC,outpatient,5,ML,248.94,174.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-04,NDC,outpatient,1,UN,5.27,3.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,16729-0443-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-61,NDC,outpatient,1,UN,6.35,4.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-00,NDC,outpatient,10,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-10,NDC,outpatient,10,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,99999-0001-96,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-01,NDC,outpatient,10,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-10,NDC,outpatient,10,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,29033-0001-01,NDC,outpatient,1,UN,5.44,3.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,42858-0701-01,NDC,outpatient,1,UN,3.89,2.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,78112-0011-03,NDC,outpatient,177,ML,17.33,12.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,00904-6305-21,NDC,outpatient,177,ML,7.09,4.963,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,49348-0991-36,NDC,outpatient,177,ML,7.88,5.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,29300-0155-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,57237-0114-90,NDC,outpatient,1,UN,2,1.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-21,NDC,outpatient,1,UN,18.55,12.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,51991-0877-33,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,59762-1710-02,NDC,outpatient,1,UN,5.59,3.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-11,NDC,outpatient,1,UN,18.55,12.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZONISAMIDE 25 MG ORAL CAPS,RX-36987,CDM,S5000,HCPCS,259,RC,68462-0128-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,23155-0833-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-20,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,63739-0327-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-01,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,31722-0520-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,00536-3445-08,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,57896-0621-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00832-1112-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-57,NDC,outpatient,1,UN,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-44,NDC,outpatient,1,UN,1.42,0.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-11,NDC,outpatient,1,UN,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00904-6505-61,NDC,outpatient,1,UN,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-45,NDC,outpatient,1,UN,1.42,0.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,49348-0521-72,NDC,outpatient,28.4,GR,6.32,4.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,00536-1277-80,NDC,outpatient,28,GR,5.24,3.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00096-0732-04,NDC,outpatient,120,ML,56.61,39.627,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00394-0859-32,NDC,outpatient,114,ML,22.83,15.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,S5000,HCPCS,259,RC,00168-0020-31,NDC,outpatient,28.35,GR,18.05,12.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,59762-0074-01,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-11,NDC,outpatient,1,UN,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-01,NDC,outpatient,1,UN,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,00574-7090-12,NDC,outpatient,1,UN,5.54,3.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,10135-0751-12,NDC,outpatient,1,UN,7.8,5.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-95,NDC,outpatient,1,UN,3.48,2.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-98,NDC,outpatient,1,UN,3.48,2.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-65,NDC,outpatient,1,UN,2.84,1.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-60,NDC,outpatient,1,UN,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-63,NDC,outpatient,1,UN,2.84,1.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-89,NDC,outpatient,1,UN,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-13,NDC,outpatient,1,UN,7.06,4.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-11,NDC,outpatient,1,UN,7.06,4.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BSS IO SOLN,RX-37579,CDM,S5000,HCPCS,259,RC,00065-0795-15,NDC,outpatient,15,ML,24.7,17.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-01,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-11,NDC,outpatient,1,UN,1.27,0.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,00406-3243-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-01,NDC,outpatient,1,UN,1.27,0.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,00406-3244-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-01,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-11,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,42858-0234-01,NDC,outpatient,1,UN,17.03,11.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,00378-0018-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,23155-0603-51,NDC,outpatient,100,ML,170.44,119.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,59762-0016-01,NDC,outpatient,100,ML,170.44,119.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,99999-0002-90,NDC,outpatient,10,ML,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-11,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-21,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-11,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-01,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,00904-6718-39,NDC,outpatient,1,UN,2.32,1.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,63824-0008-50,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-01,NDC,outpatient,1,UN,2.76,1.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-11,NDC,outpatient,1,UN,2.76,1.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,62135-0750-47,NDC,outpatient,5,ML,21.74,15.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,99999-0002-50,NDC,outpatient,5,ML,1.16,0.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,54838-0502-80,NDC,outpatient,5,ML,2.88,2.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYZINE HCL 10 MG ORAL TABS,RX-3772,CDM,S5000,HCPCS,259,RC,63739-0483-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,00904-6617-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,63739-0486-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TALC 5 G PL SUSR,RX-37812,CDM,S5000,HCPCS,259,RC,63256-0200-05,NDC,outpatient,1,UN,458.35,320.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-11,NDC,outpatient,1,UN,64.87,45.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,00904-7067-04,NDC,outpatient,1,UN,76.53,53.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,55513-0073-30,NDC,outpatient,1,UN,75.45,52.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-21,NDC,outpatient,1,UN,64.87,45.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,70436-0007-04,NDC,outpatient,1,UN,1.94,1.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ORPHENADRINE CITRATE ER 100 MG ORAL TB12,RX-38213,CDM,S5000,HCPCS,259,RC,43386-0480-24,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,42291-0522-01,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,62559-0530-01,NDC,outpatient,1,UN,2.1,1.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,00228-2778-11,NDC,outpatient,1,UN,6.75,4.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00228-2779-11,NDC,outpatient,1,UN,8.57,5.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00527-4117-37,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,00228-2780-11,NDC,outpatient,1,UN,10.29,7.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,42291-0524-01,NDC,outpatient,1,UN,2.42,1.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-30,NDC,outpatient,30,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,99999-0001-83,NDC,outpatient,30,ML,2.16,1.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-30,NDC,outpatient,30,ML,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-65,NDC,outpatient,15,ML,1.01,0.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-00,NDC,outpatient,30,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-64,NDC,outpatient,1,UN,12.96,9.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-06,NDC,outpatient,1,UN,12.96,9.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 200 MG ORAL TABS,RX-3841,CDM,S5000,HCPCS,259,RC,00904-7914-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 600 MG ORAL TABS,RX-3844,CDM,S5000,HCPCS,259,RC,00904-5854-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-09,NDC,outpatient,1,ML,15.58,10.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-01,NDC,outpatient,4,ML,53.96,37.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IBUPROFEN 800 MG ORAL TABS,RX-3845,CDM,S5000,HCPCS,259,RC,00904-5855-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUOXETINE HCL 20 MG/5ML ORAL SOLN,RX-38488,CDM,S5000,HCPCS,259,RC,00121-4721-05,NDC,outpatient,5,ML,14.38,10.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IMIPRAMINE HCL 10 MG ORAL TABS,RX-3860,CDM,S5000,HCPCS,259,RC,69584-0425-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IMIPRAMINE HCL 25 MG ORAL TABS,RX-3861,CDM,S5000,HCPCS,259,RC,69584-0426-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,S5000,HCPCS,259,RC,24208-0780-55,NDC,outpatient,3.5,GR,57.59,40.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,00228-2571-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,62559-0511-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SELENIUM SULFIDE 1 % EX SHAM,RX-38961,CDM,S5000,HCPCS,259,RC,00536-1995-53,NDC,outpatient,207,ML,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PEG 3350-KCL-NABCB-NACL-NASULF 240 G ORAL SOLR,RX-38965,CDM,S5000,HCPCS,259,RC,43386-0060-19,NDC,outpatient,4000,ML,53.4,37.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-11,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-15,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,S5000,HCPCS,259,RC,69344-0102-33,NDC,outpatient,1,UN,1095.8,767.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAXIMIN 200 MG ORAL TABS,RX-39063,CDM,S5000,HCPCS,259,RC,65649-0301-03,NDC,outpatient,1,UN,43.55,30.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMILORIDE HCL 5 MG ORAL TABS,RX-391,CDM,S5000,HCPCS,259,RC,00574-0292-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,16714-0769-01,NDC,outpatient,15,GR,25.04,17.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,69315-0306-15,NDC,outpatient,15,GR,24.5,17.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,00832-0465-15,NDC,outpatient,15,GR,37.52,26.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68308-0152-15,NDC,outpatient,15,GR,27.84,19.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68382-0370-01,NDC,outpatient,15,GR,31.18,21.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EMTRICITABINE-TENOFOVIR DF 200-300 MG ORAL TABS,RX-39255,CDM,S5000,HCPCS,259,RC,61958-0701-01,NDC,outpatient,1,UN,265.08,185.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,00904-7043-04,NDC,outpatient,1,UN,3.3,2.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-11,NDC,outpatient,1,UN,3.39,2.373,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-21,NDC,outpatient,1,UN,3.39,2.373,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,00904-7044-61,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,57237-0018-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-01,NDC,outpatient,1,UN,3.41,2.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-11,NDC,outpatient,1,UN,3.41,2.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-93,NDC,outpatient,1,UN,20.14,14.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-31,NDC,outpatient,1,UN,20.14,14.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,99999-0002-80,NDC,outpatient,6,ML,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,68180-0723-04,NDC,outpatient,60,ML,87.31,61.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,65862-0219-60,NDC,outpatient,60,ML,88.92,62.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE ER 500 MG ORAL CPCR,RX-39575,CDM,S5000,HCPCS,259,RC,54092-0191-12,NDC,outpatient,1,UN,24.97,17.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,51552-0019-44,NDC,outpatient,14,ML,5.44,3.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,48433-0230-15,NDC,outpatient,14,ML,132.64,92.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-95,NDC,outpatient,1,UN,6.9,4.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-25,NDC,outpatient,1,UN,6.9,4.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-10,NDC,outpatient,5,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-10,NDC,outpatient,5,ML,12.98,9.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-01,NDC,outpatient,5,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-01,NDC,outpatient,5,ML,12.98,9.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,63323-0424-05,NDC,outpatient,5,ML,15.68,10.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,00527-1948-68,NDC,outpatient,10,ML,85.98,60.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,99999-0002-53,NDC,outpatient,10,ML,37.07,25.949,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-90,NDC,outpatient,1,UN,49.37,34.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-42,NDC,outpatient,1,UN,24.73,17.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-52,NDC,outpatient,1,UN,24.73,17.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-45,NDC,outpatient,1,UN,49.37,34.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-20,NDC,outpatient,1,UN,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-01,NDC,outpatient,1,UN,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,51079-0608-20,NDC,outpatient,1,UN,10.74,7.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,60687-0629-21,NDC,outpatient,1,UN,4.19,2.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-04,NDC,outpatient,5,ML,14,9.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-82,NDC,outpatient,10,ML,19.54,13.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-01,NDC,outpatient,10,ML,19.54,13.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-61,NDC,outpatient,180,ML,12.46,8.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIFAMPIN 10 MG/ML ORAL SUSPENSION,RX-400484,CDM,S5000,HCPCS,259,RC,99999-0001-44,NDC,outpatient,120,ML,34,23.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,99999-0002-12,NDC,outpatient,12.5,ME,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,SH040-0403-01,NDC,outpatient,12.5,ME,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,,,outpatient,12.5,ME,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFAZOLIN EYE DROPS 50 MG/ML 20 ML BOTTLE,RX-400598,CDM,S5000,HCPCS,259,RC,SH408-0378-01,NDC,outpatient,20,ML,18.41,12.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,,,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,SH040-0620-01,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISONIAZID 100 MG ORAL TABS,RX-4026,CDM,S5000,HCPCS,259,RC,00555-0066-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-25,NDC,outpatient,4,ML,8,5.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-16,NDC,outpatient,20,ML,18.34,12.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-01,NDC,outpatient,4,ML,8,5.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-73,NDC,outpatient,20,ML,18.34,12.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-05,NDC,outpatient,5,ML,1453.64,1017.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-07,NDC,outpatient,5,ML,1453.64,1017.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,00548-9502-00,NDC,outpatient,5,ML,246.51,172.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,69918-0560-30,NDC,outpatient,1,UN,7.56,5.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,59762-0118-03,NDC,outpatient,1,UN,22.5,15.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SOLIFENACIN SUCCINATE 5 MG ORAL TABS,RX-40392,CDM,S5000,HCPCS,259,RC,51248-0150-01,NDC,outpatient,1,UN,52.84,36.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,00743-1203-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,74312-0035-95,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-11,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ISOSORBIDE DINITRATE 20 MG ORAL TABS,RX-4065,CDM,S5000,HCPCS,259,RC,00904-6620-61,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-10,NDC,outpatient,500,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-20,NDC,outpatient,250,ML,30.14,21.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROMORPHONE 100 MG/100 ML INFUSION,RX-4080055,CDM,S5000,HCPCS,250,RC,99999-0000-26,NDC,outpatient,100,ML,168.65,118.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM ADDVANTAGE INFUSION IN NS,RX-4080056,CDM,S5000,HCPCS,250,RC,99999-0000-00,NDC,outpatient,100,ML,54.5,38.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0202-40,NDC,outpatient,250,ML,236.1,165.27,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0229-40,NDC,outpatient,250,ML,277.66,194.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70092-1093-37,NDC,outpatient,250,ML,130.86,91.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,99999-0001-54,NDC,outpatient,250,ML,37.36,26.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,99999-9990-03,NDC,outpatient,250,ML,37.81,26.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,70004-0442-40,NDC,outpatient,250,ML,112.79,78.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE INFUSION 250 MG IN D5W 250 ML PREMIX,RX-4080096,CDM,S5000,HCPCS,250,RC,99999-0001-61,NDC,outpatient,250,ML,35.02,24.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-25,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-22,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-01,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-00,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,00065-0426-36,NDC,outpatient,15,ML,27.17,19.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,57896-0181-05,NDC,outpatient,15,ML,5.55,3.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAFCILLIN SODIUM 1 G IJ WRAPPER,RX-4080106,CDM,S5000,HCPCS,250,RC,63323-0327-10,NDC,outpatient,1,UN,15.49,10.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,44567-0222-10,NDC,outpatient,1,UN,90.46,63.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,55150-0123-15,NDC,outpatient,1,UN,30.45,21.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,63323-0328-20,NDC,outpatient,1,UN,24.64,17.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70004-0781-40,NDC,outpatient,250,ML,123.78,86.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70092-1650-05,NDC,outpatient,250,ML,102.2,71.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,71266-5020-02,NDC,outpatient,250,ML,112.97,79.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,42852-0838-25,NDC,outpatient,250,ML,158.85,111.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70004-0812-40,NDC,outpatient,250,ML,93.12,65.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70092-9170-05,NDC,outpatient,250,ML,146.26,102.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,70004-0811-40,NDC,outpatient,250,ML,109.23,76.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,71506-0010-58,NDC,outpatient,250,ML,88.76,62.132,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN DEXTROSE 1250 MG/250 ML IV SOLN,RX-4080122,CDM,S5000,HCPCS,250,RC,99999-0000-46,NDC,outpatient,275,ML,64.38,45.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN HCL IN DEXTROSE 1500 MG/250 ML IV SOLN,RX-4080123,CDM,S5000,HCPCS,250,RC,99999-0000-47,NDC,outpatient,280,ML,80.8,56.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARDIOPLEGIA SOLN HIGH POTASSIUM 4:1 INDUCTION,RX-4080154,CDM,S5000,HCPCS,250,RC,72196-0101-01,NDC,outpatient,500,ML,673.36,471.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARDIOPLEGIA SOLN LOW POTASSION 4:1 REPERFUSATE,RX-4080155,CDM,S5000,HCPCS,250,RC,71285-0007-01,NDC,outpatient,238.75,ML,1537.64,1076.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARDIOPLEGIA SOLN LOW POTASSIUM 4:1 MAINTENANCE,RX-4080156,CDM,S5000,HCPCS,250,RC,72196-0104-01,NDC,outpatient,1000,ML,1042.09,729.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CONCENTRATED DILAUDID 1 MG/ML PCA,RX-4080157,CDM,S5000,HCPCS,250,RC,70004-0303-62,NDC,outpatient,50,ML,212.25,148.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILAUDID 0.2 MG/ML PCA (HYDROMORPHONE),RX-4080159,CDM,S5000,HCPCS,250,RC,70004-0300-62,NDC,outpatient,50,ML,69.63,48.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRISMASATE K 0/CA 3.5 CRRT SOLUTION,RX-4080163,CDM,S5000,HCPCS,250,RC,00000-1053-53,NDC,outpatient,5000,ML,188.44,131.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-9202-75,NDC,outpatient,100,ML,251.94,176.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,99999-0001-52,NDC,outpatient,100,ML,30.84,21.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70004-0231-64,NDC,outpatient,100,ML,109.23,76.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-1202-75,NDC,outpatient,100,ML,258.44,180.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 5 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080169,CDM,S5000,HCPCS,250,RC,99999-0001-55,NDC,outpatient,100,ML,34.55,24.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080170,CDM,S5000,HCPCS,250,RC,99999-0000-03,NDC,outpatient,100,ML,67.18,47.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-12,NDC,outpatient,2,ML,6.33,4.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-22,NDC,outpatient,2,ML,6.33,4.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-01,NDC,outpatient,1,ML,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-21,NDC,outpatient,1,ML,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,70004-0756-12,NDC,outpatient,10,ML,39.83,27.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,99999-0001-50,NDC,outpatient,10,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-10,NDC,outpatient,5,ML,14.35,10.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-10,NDC,outpatient,10,ML,22.61,15.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-01,NDC,outpatient,5,ML,14.35,10.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-01,NDC,outpatient,10,ML,22.61,15.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE-LIDOCAINE 0.3%-1.5% OINT,RX-408020,CDM,S5000,HCPCS,259,RC,00000-0000-03,NDC,outpatient,30,GR,333.75,233.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-05,NDC,outpatient,5,ML,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-15,NDC,outpatient,5,ML,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,00536-1211-95,NDC,outpatient,28,GR,13.84,9.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,71399-2829-01,NDC,outpatient,28,GR,14.21,9.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COCOA BUTTER STICK,RX-4080278,CDM,S5000,HCPCS,259,RC,07570-7011-00,NDC,outpatient,30,ML,4.41,3.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAPSAICIN 0.025 % EX CREAM WRAPPER,RX-4080289,CDM,S5000,HCPCS,259,RC,00536-2525-25,NDC,outpatient,60,GR,10.95,7.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,00168-0357-55,NDC,outpatient,5,GR,29.95,20.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-31,NDC,outpatient,30,GR,87.18,61.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-04,NDC,outpatient,5,GR,24.68,17.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,SH408-0358-01,NDC,outpatient,20,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,99999-0000-54,NDC,outpatient,20,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MULTIVITAMIN CHILDRENS ORAL CHEW WRAPPER,RX-4080360,CDM,S5000,HCPCS,259,RC,80681-0049-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMPHOTERICIN B EYE DROPS 0.2 MG/ML 10 ML BOTTLE,RX-4080376,CDM,S5000,HCPCS,259,RC,SH408-0376-01,NDC,outpatient,10,ML,61.86,43.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 1 MG/ML ORAL SUSPENSION 81 ML FOR ASA DESENSITIZATION,RX-4080380,CDM,S5000,HCPCS,259,RC,SH408-0380-01,NDC,outpatient,81,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFTAZIDIME EYE DROPS 22.5 MG/ML SYRINGE,RX-4080386,CDM,S5000,HCPCS,259,RC,99999-0000-32,NDC,outpatient,1,ML,37.46,26.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN MOUTH WASH 3 MG/ML,RX-4080388,CDM,S5000,HCPCS,259,RC,99999-0000-33,NDC,outpatient,250,ML,10.02,7.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,88888-0926-28,NDC,outpatient,3,ML,22.25,15.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,99999-0003-19,NDC,outpatient,3,ML,14.57,10.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,69623-0801-14,NDC,outpatient,3,ML,35.6,24.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,70092-1135-44,NDC,outpatient,3,ML,49.22,34.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAG SULFATE-GLYCERIN-WATER ENEMA 180 ML,RX-4080412,CDM,S5000,HCPCS,259,RC,00000-0000-02,NDC,outpatient,180,ML,28.04,19.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE ORAL SUSPENSION 1 MG/ML,RX-4080416,CDM,S5000,HCPCS,259,RC,99999-0003-46,NDC,outpatient,12.5,ML,1.93,1.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-20,NDC,outpatient,20,ML,13.44,9.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0885-16,NDC,outpatient,480,ML,1149.17,804.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,42799-0815-01,NDC,outpatient,237,ML,151.87,106.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-35,NDC,outpatient,20,ML,13.44,9.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-20,NDC,outpatient,20,ML,98.71,69.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-37,NDC,outpatient,240,ML,1184.42,829.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-08,NDC,outpatient,237,ML,159.26,111.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,69238-2122-20,NDC,outpatient,20,ML,14.96,10.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-36,NDC,outpatient,5,ML,2.94,2.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,99999-0001-12,NDC,outpatient,1,ML,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,SH408-0423-01,NDC,outpatient,1,ML,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 1 MEQ/ML 1 ML ORAL SYRINGE,RX-4080424,CDM,S5000,HCPCS,259,RC,99999-0001-25,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE-MINERAL OIL-GLYCERIN ENEMA,RX-4080430,CDM,S5000,HCPCS,259,RC,SH408-0430-01,NDC,outpatient,135,ML,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,,,outpatient,1.5,ML,1.92,1.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,99999-0001-26,NDC,outpatient,1.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SPIRONOLACTONE 6 MG/3 ML ORAL SYRINGE,RX-4080435,CDM,S5000,HCPCS,259,RC,99999-0000-28,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFAZOLIN IVPB 2 G IN 100 ML NS PREMIX,RX-4080437,CDM,S5000,HCPCS,250,RC,99999-0000-45,NDC,outpatient,100,ML,47.78,33.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0449-01,NDC,outpatient,2,ML,22.21,15.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0450-01,NDC,outpatient,0.1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN EYE SOLUTION 25 MG/ML,RX-4080451,CDM,S5000,HCPCS,259,RC,SH408-0451-01,NDC,outpatient,20,ML,54.07,37.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VANCOMYCIN EYE SOLUTION 50 MG/ML ,RX-4080452,CDM,S5000,HCPCS,259,RC,SH408-0452-01,NDC,outpatient,20,ML,54.07,37.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,76282-0327-01,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,99999-0002-46,NDC,outpatient,0.5,ME,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,51672-4027-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,99999-0002-47,NDC,outpatient,1.25,ME,4.53,3.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,51672-4029-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0775-40,NDC,outpatient,250,ML,320.83,224.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1468-05,NDC,outpatient,250,ML,192.22,134.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0533-25,NDC,outpatient,250,ML,140.6,98.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1652-05,NDC,outpatient,250,ML,216.97,151.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-03,NDC,outpatient,250,ML,261.87,183.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0315-25,NDC,outpatient,250,ML,118.35,82.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0785-40,NDC,outpatient,250,ML,301.03,210.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-01,NDC,outpatient,250,ML,261.87,183.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,48433-0108-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,00904-7191-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70092-1084-44,NDC,outpatient,5,ML,61.01,42.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-13,NDC,outpatient,3,ML,51.74,36.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70004-0750-09,NDC,outpatient,5,ML,78.06,54.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,69374-0932-03,NDC,outpatient,3,ML,45.62,31.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-30,NDC,outpatient,3,ML,51.74,36.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,00574-0508-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,20555-0019-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,00065-0518-01,NDC,outpatient,3.5,GR,29.43,20.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,10119-0022-39,NDC,outpatient,3.5,GR,30.17,21.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 1 % FOR PLEURODESIS,RX-4080551,CDM,S5000,HCPCS,250,RC,99999-0003-43,NDC,outpatient,50,ML,13.37,9.359,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-01,NDC,outpatient,15,ML,59.41,41.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-09,NDC,outpatient,5,ML,93.68,65.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-11,NDC,outpatient,15,ML,59.41,41.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-29,NDC,outpatient,5,ML,93.68,65.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,10135-0701-04,NDC,outpatient,113,GR,13.58,9.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,00799-0001-04,NDC,outpatient,113,GR,20.12,14.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM 100 MG ADDVANTAGE INFUSION IN D5W 100 ML,RX-4080558,CDM,S5000,HCPCS,250,RC,99999-0000-01,NDC,outpatient,100,ML,48.09,33.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HIV POST EXPOSURE KIT,RX-4080559,CDM,S5000,HCPCS,259,RC,SH408-0559-01,NDC,outpatient,1,UN,1178.97,825.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE 0.125 % IN 100 ML NS NERVE BLOCK CASSETTE,RX-4080570,CDM,S5000,HCPCS,250,RC,61553-0829-48,NDC,outpatient,100,ML,76.93,53.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080589,CDM,S5000,HCPCS,250,RC,99999-0000-04,NDC,outpatient,100,ML,79.95,55.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VEIN GRAFT SOLUTION,RX-4080591,CDM,S5000,HCPCS,250,RC,99999-0000-07,NDC,outpatient,505.67,ML,73.5,51.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLECAINIDE ACETATE 20 MG/ML ORAL SUSP,RX-4080607,CDM,S5000,HCPCS,259,RC,99999-0003-52,NDC,outpatient,2.5,ML,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYOSCYAMINE SULFATE 0.125 MG SL SUBL WRAPPER,RX-4080632,CDM,S5000,HCPCS,259,RC,42192-0338-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-51,NDC,outpatient,60,ML,33.11,23.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-46,NDC,outpatient,60,ML,33.11,23.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0923-41,NDC,outpatient,60,ML,80.91,56.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,10006-0700-28,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM GLUCONATE 500 MG ORAL TABS WRAPPER,RX-4080642,CDM,S5000,HCPCS,259,RC,60258-0172-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GI COCKTAIL SUSPENSION,RX-4080647,CDM,S5000,HCPCS,259,RC,99999-0000-39,NDC,outpatient,55,ML,82.33,57.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARDIOPLEGIA SOLN DEL NIDO,RX-4080676,CDM,S5000,HCPCS,250,RC,99999-0004-39,NDC,outpatient,1052.8,ML,113.01,79.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1512-46,NDC,outpatient,10,ML,20.96,14.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1617-46,NDC,outpatient,10,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IV SOLN MINI-BAG 100 ML,RX-4080711,CDM,S5000,HCPCS,250,RC,00338-0553-18,NDC,outpatient,100,ML,29.37,20.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HYDROCORTISONE ORAL SUSPENSION 2.5 MG/ML COMPOUNDED PRODUCT,RX-4080716,CDM,S5000,HCPCS,259,RC,99999-0000-80,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUDROCORTISONE ACETATE SUSP 0.2 MG/ML,RX-4080718,CDM,S5000,HCPCS,259,RC,99999-0000-81,NDC,outpatient,1,ML,4.96,3.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,62103-0323-02,NDC,outpatient,57,GR,14.72,10.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,74300-0000-71,NDC,outpatient,113,GR,26.15,18.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALOXONE INHALATION KIT - HOSPITAL USE ONLY,RX-4080774,CDM,S5000,HCPCS,259,RC,99999-0000-90,NDC,outpatient,1,UN,110.81,77.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-11,NDC,outpatient,20,ML,230.78,161.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-01,NDC,outpatient,20,ML,230.78,161.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFAZOLIN IVPB 3 G IN 100 ML NS PREMIX,RX-4080801,CDM,S5000,HCPCS,250,RC,99999-0001-10,NDC,outpatient,130,ML,33.43,23.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,70092-1433-50,NDC,outpatient,50,ML,216.36,151.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,99999-0000-98,NDC,outpatient,50,ML,59.06,41.342,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 5 % MOUTHWASH ORAL SUSPENSION,RX-4080811,CDM,S5000,HCPCS,259,RC,99999-0001-06,NDC,outpatient,169,ML,77.47,54.229,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,99999-0001-17,NDC,outpatient,5,ML,1.37,0.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,50580-0170-05,NDC,outpatient,5,ML,1.37,0.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,00045-0166-04,NDC,outpatient,120,ML,28.31,19.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BABY BUTT BALM,RX-4080852,CDM,S5000,HCPCS,259,RC,99999-0001-13,NDC,outpatient,118.7,GR,70.96,49.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAZOLAMIDE 25 MG/ML SUSPENSION,RX-4080874,CDM,S5000,HCPCS,259,RC,99999-0001-21,NDC,outpatient,5,ML,10.93,7.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00005-4344-62,NDC,outpatient,15,ML,2.09,1.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-61,NDC,outpatient,15,ML,7.68,5.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-59,NDC,outpatient,15,ML,7.68,5.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-15,NDC,outpatient,15,ML,2.32,1.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,99999-0002-20,NDC,outpatient,15,ML,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-30,NDC,outpatient,15,ML,2.32,1.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,69618-0008-58,NDC,outpatient,15,ML,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,38779-1284-08,NDC,outpatient,8,ML,2.35,1.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-08,NDC,outpatient,8,ML,47.67,33.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,49452-3081-02,NDC,outpatient,8,ML,2.35,1.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-02,NDC,outpatient,8,ML,9.33,6.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0170-05,NDC,outpatient,5,ML,35.56,24.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-16,NDC,outpatient,15,ML,169.35,118.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-01,NDC,outpatient,5,ML,79.73,55.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-06,NDC,outpatient,5,ML,79.73,55.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-01,NDC,outpatient,15,ML,169.35,118.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-10,NDC,outpatient,5,ML,10.46,7.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,25021-0662-05,NDC,outpatient,5,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-05,NDC,outpatient,10,ML,22.61,15.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-06,NDC,outpatient,10,ML,22.61,15.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-01,NDC,outpatient,5,ML,24.17,16.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-01,NDC,outpatient,5,ML,10.46,7.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,43066-0007-10,NDC,outpatient,5,ML,8.46,5.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-05,NDC,outpatient,5,ML,7.05,4.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,67457-0228-02,NDC,outpatient,5,ML,6.84,4.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0226-10,NDC,outpatient,10,ML,18.46,12.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,66794-0228-41,NDC,outpatient,5,ML,6.84,4.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-10,NDC,outpatient,5,ML,24.17,16.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0225-05,NDC,outpatient,5,ML,9.23,6.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-02,NDC,outpatient,5,ML,7.05,4.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMIODARONE ORAL SUSPENSION 40 MG/ML,RX-4080970,CDM,S5000,HCPCS,259,RC,99999-0001-63,NDC,outpatient,10,ML,2.04,1.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 100 MG/100 ML IN D5W PF PREMIX,RX-4081012,CDM,S5000,HCPCS,250,RC,99999-0000-99,NDC,outpatient,100,ML,312.37,218.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,42023-0243-01,NDC,outpatient,10,ML,42.55,29.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-10,NDC,outpatient,10,ML,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-07,NDC,outpatient,10,ML,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,99999-0000-87,NDC,outpatient,100,ML,34.01,23.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DILTIAZEM 100 MG IN 100 ML NS BATCHED INFUSION,RX-4081050,CDM,S5000,HCPCS,250,RC,99999-0002-64,NDC,outpatient,100,ML,56.68,39.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
URSODIOL 50 MG/ML ORAL SUSPENSION,RX-4081064,CDM,S5000,HCPCS,259,RC,99999-0002-69,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPRENORPHINE-NALOXONE (SUBOXONE) SL FILM 8 MG-2 MG KIT,RX-4081171,CDM,S5000,HCPCS,259,RC,99999-0003-16,NDC,outpatient,1,UN,142.33,99.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-34,NDC,outpatient,5,ML,17.92,12.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-11,NDC,outpatient,5,ML,17.92,12.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,63323-0208-05,NDC,outpatient,5,ML,7.41,5.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,76329-3390-01,NDC,outpatient,5,ML,27.15,19.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-05,NDC,outpatient,5,ML,19.63,13.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-15,NDC,outpatient,5,ML,19.63,13.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,12.64,8.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,12.64,8.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 100 MG/100 ML IN NS PF PREMIX,RX-4081195,CDM,S5000,HCPCS,250,RC,99999-0003-26,NDC,outpatient,100,ML,312.37,218.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANTOPRAZOLE 80 MG/100 ML INFUSION PREMIX,RX-4081208,CDM,S5000,HCPCS,250,RC,99999-0000-77,NDC,outpatient,100,ML,36.56,25.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-10,NDC,outpatient,200,ML,242.06,169.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-01,NDC,outpatient,200,ML,242.06,169.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 3 % IV ONCE,RX-4081432,CDM,S5000,HCPCS,250,RC,99999-0003-86,NDC,outpatient,100,ML,18.06,12.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FAMOTIDINE IN NACL 20-0.9 MG/10 ML-% IV SOSY,RX-4081444,CDM,S5000,HCPCS,250,RC,99999-0003-96,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM HYALURONATE 10 MG/ML IO SOLN WRAPPER,RX-4081458,CDM,S5000,HCPCS,250,RC,05047-4508-38,NDC,outpatient,0.4,ML,397.92,278.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV *BATCHED*,RX-4081542,CDM,S5000,HCPCS,250,RC,99999-0004-35,NDC,outpatient,50,ML,157.29,110.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,70092-1518-75,NDC,outpatient,100,ML,209.09,146.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,99999-0004-53,NDC,outpatient,100,ML,48.85,34.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,0.5,UN,1,0.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,0.5,UN,4.12,2.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,0.5,UN,2.9,2.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHADONE 10 MG TABLET DISCHARGE KIT,RX-4081610,CDM,S5000,HCPCS,259,RC,99999-0004-50,NDC,outpatient,1,UN,6.15,4.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRISMASATE K 4/CA 2.5 CRRT SOLUTION,RX-40840045,CDM,S5000,HCPCS,250,RC,SH408-4045-01,NDC,outpatient,5000,ML,188.44,131.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRISMASATE K 2/CA 0 CRRT SOLUTION,RX-40840046,CDM,S5000,HCPCS,250,RC,SH408-4046-01,NDC,outpatient,5000,ML,188.44,131.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0012-66,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0011-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,47335-0835-83,NDC,outpatient,1,UN,5.27,3.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,63629-2364-01,NDC,outpatient,1,UN,6.03,4.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,S5000,HCPCS,259,RC,00597-0087-17,NDC,outpatient,12.9,GR,1940.98,1358.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENTECAVIR 0.5 MG ORAL TABS,RX-41147,CDM,S5000,HCPCS,259,RC,00003-1611-12,NDC,outpatient,1,UN,197.48,138.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENTECAVIR 1 MG ORAL TABS,RX-41148,CDM,S5000,HCPCS,259,RC,65862-0842-30,NDC,outpatient,1,UN,8.95,6.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-11,NDC,outpatient,1,UN,21.37,14.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-47,NDC,outpatient,1,UN,21.37,14.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-16,NDC,outpatient,1,UN,50.62,35.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-98,NDC,outpatient,1,UN,50.62,35.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,65862-0936-30,NDC,outpatient,1,UN,5.24,3.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,49483-0687-03,NDC,outpatient,1,UN,4.45,3.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,52817-0830-04,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,99999-0002-52,NDC,outpatient,10,ML,6.37,4.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-01,NDC,outpatient,0.5,ML,58.03,40.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-00,NDC,outpatient,0.5,ML,58.19,40.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-02,NDC,outpatient,0.5,ML,64.31,45.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-05,NDC,outpatient,0.5,ML,58.03,40.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OMEGA-3-ACID ETHYL ESTERS 1 G ORAL CAPS,RX-41822,CDM,S5000,HCPCS,259,RC,64380-0761-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,64380-0789-32,NDC,outpatient,35.44,GR,61.67,43.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,65162-0918-38,NDC,outpatient,35.44,GR,50,35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,00904-6671-04,NDC,outpatient,1,UN,2.21,1.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,63739-0072-33,NDC,outpatient,1,UN,2.21,1.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METRONIDAZOLE 1 % EX GEL,RX-41899,CDM,S5000,HCPCS,259,RC,51672-4215-03,NDC,outpatient,60,GR,258.99,181.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AVEENO SOOTHING BATH TREATMENT EX PACK,RX-41904,CDM,S5000,HCPCS,259,RC,08137-0036-40,NDC,outpatient,1,UN,2.74,1.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-11,NDC,outpatient,1,UN,11.47,8.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,70010-0028-03,NDC,outpatient,1,UN,6.31,4.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-15,NDC,outpatient,1,UN,11.47,8.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,00054-0622-63,NDC,outpatient,5,ML,3.5,2.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,99999-0003-12,NDC,outpatient,5,ML,5.06,3.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,50228-0350-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-01,NDC,outpatient,1,UN,1.96,1.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-11,NDC,outpatient,1,UN,1.96,1.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00904-6992-61,NDC,outpatient,1,UN,2.3,1.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,72205-0012-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00071-1013-41,NDC,outpatient,1,UN,45.77,32.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00904-7000-61,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-11,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,62332-0121-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00071-1014-41,NDC,outpatient,1,UN,45.77,32.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-01,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,69238-1313-09,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,00904-7001-61,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,62332-0122-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00071-1016-41,NDC,outpatient,1,UN,45.77,32.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00904-7002-61,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,S5000,HCPCS,250,RC,42023-0113-10,NDC,outpatient,20,ML,41.57,29.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,S5000,HCPCS,250,RC,42023-0115-10,NDC,outpatient,5,ML,53.45,37.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-10,NDC,outpatient,10,ML,23.23,16.261,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-01,NDC,outpatient,10,ML,23.23,16.261,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-15,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,70756-0201-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-11,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,00781-1487-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-11,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-01,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,00054-0057-46,NDC,outpatient,60,ML,612.5,428.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,99999-0004-03,NDC,outpatient,2.5,ML,25.53,17.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-01,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-11,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,S5000,HCPCS,259,RC,76329-6300-05,NDC,outpatient,4,ML,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMMONIA AROMATIC IN INHA,RX-439,CDM,S5000,HCPCS,259,RC,67777-0251-01,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00054-8496-19,NDC,outpatient,1,UN,7.46,5.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00555-0484-02,NDC,outpatient,1,UN,5.35,3.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-01,NDC,outpatient,1,UN,1.54,1.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-11,NDC,outpatient,1,UN,1.54,1.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-01,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-20,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-01,NDC,outpatient,1,UN,1.67,1.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-11,NDC,outpatient,1,UN,1.67,1.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-20,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-01,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,00074-4552-11,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-20,NDC,outpatient,1,UN,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-01,NDC,outpatient,1,UN,2.04,1.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-11,NDC,outpatient,1,UN,2.04,1.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-01,NDC,outpatient,1,UN,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,00074-6624-11,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-20,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-01,NDC,outpatient,1,UN,3.14,2.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-20,NDC,outpatient,1,UN,3.14,2.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,60687-0530-01,NDC,outpatient,1,UN,2.51,1.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,00074-7069-11,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,60432-0465-51,NDC,outpatient,50,ML,131.72,92.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00527-6004-80,NDC,outpatient,50,ML,75.88,53.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00054-3505-47,NDC,outpatient,50,ML,107.03,74.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 0.5 % IJ SOLN,RX-4451,CDM,S5000,HCPCS,250,RC,63323-0484-57,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-01,NDC,outpatient,20,ML,4.63,3.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-17,NDC,outpatient,50,ML,8.23,5.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-02,NDC,outpatient,50,ML,8.23,5.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-16,NDC,outpatient,20,ML,4.63,3.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-01,NDC,outpatient,20,ML,5.14,3.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-01,NDC,outpatient,2,ML,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0254-10,NDC,outpatient,10,ML,3.76,2.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0255-20,NDC,outpatient,20,ML,4.22,2.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-02,NDC,outpatient,2,ML,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-01,NDC,outpatient,10,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-27,NDC,outpatient,20,ML,18.2,12.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-16,NDC,outpatient,20,ML,5.14,3.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-02,NDC,outpatient,20,ML,18.2,12.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-17,NDC,outpatient,10,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-26,NDC,outpatient,20,ML,8.02,5.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,65862-0016-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,16714-0298-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,00093-2178-01,NDC,outpatient,1,UN,3.21,2.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,59762-1207-01,NDC,outpatient,1,UN,3.28,2.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,51862-0321-01,NDC,outpatient,1,UN,3.45,2.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN 500 MG ORAL CAPS,RX-451,CDM,S5000,HCPCS,259,RC,16714-0299-03,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LITHIUM CARBONATE 150 MG ORAL CAPS,RX-4528,CDM,S5000,HCPCS,259,RC,00054-8526-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,00054-8527-25,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,31722-0545-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00093-4155-79,NDC,outpatient,80,ML,14.6,10.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,99999-0002-83,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00143-9889-15,NDC,outpatient,150,ML,20.7,14.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-11,NDC,outpatient,1,UN,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-01,NDC,outpatient,1,UN,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-20,NDC,outpatient,1,UN,3,2.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-01,NDC,outpatient,1,UN,3,2.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00121-0770-01,NDC,outpatient,30,ML,33.11,23.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,99999-0001-38,NDC,outpatient,1,ML,3.55,2.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00054-3532-44,NDC,outpatient,30,ML,100.26,70.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,13107-0083-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00093-3425-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,69315-0904-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00093-3426-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00904-6008-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOXAPINE SUCCINATE 25 MG ORAL CAPS,RX-4600,CDM,S5000,HCPCS,259,RC,00591-0371-01,NDC,outpatient,1,UN,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LOXAPINE SUCCINATE 5 MG ORAL CAPS,RX-4601,CDM,S5000,HCPCS,259,RC,00591-0369-01,NDC,outpatient,1,UN,1.31,0.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MAGNESIUM CITRATE 1.745 GM/30ML ORAL SOLN,RX-4711,CDM,S5000,HCPCS,259,RC,70677-1111-01,NDC,outpatient,296,ML,7.91,5.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-03,NDC,outpatient,500,ML,80.53,56.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-03,NDC,outpatient,500,ML,93.88,65.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-02,NDC,outpatient,250,ML,79.42,55.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-13,NDC,outpatient,500,ML,93.88,65.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEDROXYPROGESTERONE ACETATE 10 MG ORAL TABS,RX-4854,CDM,S5000,HCPCS,259,RC,00555-0779-02,NDC,outpatient,1,UN,1.07,0.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MEDROXYPROGESTERONE ACETATE 2.5 MG ORAL TABS,RX-4855,CDM,S5000,HCPCS,259,RC,00555-0872-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-23,NDC,outpatient,1,UN,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00054-0710-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-62,NDC,outpatient,1,UN,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-62,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-23,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHAZOLAMIDE 50 MG ORAL TABS,RX-4962,CDM,S5000,HCPCS,259,RC,00574-0791-01,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,31722-0533-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,76385-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,00904-7057-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-11,NDC,outpatient,1,UN,5.13,3.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,00406-1144-01,NDC,outpatient,1,UN,1.43,1.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-21,NDC,outpatient,1,UN,5.13,3.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPREDNISOLONE 16 MG ORAL TABS,RX-4992,CDM,S5000,HCPCS,259,RC,59762-0050-01,NDC,outpatient,1,UN,8.54,5.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-11,NDC,outpatient,1,UN,4.95,3.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-01,NDC,outpatient,1,UN,4.95,3.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,00904-6914-61,NDC,outpatient,1,UN,4.37,3.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-01,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-11,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METRONIDAZOLE 250 MG ORAL TABS,RX-5015,CDM,S5000,HCPCS,259,RC,00904-7156-61,NDC,outpatient,1,UN,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,29300-0227-01,NDC,outpatient,1,UN,1.76,1.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-11,NDC,outpatient,1,UN,2.17,1.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-01,NDC,outpatient,1,UN,2.17,1.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,S5000,HCPCS,259,RC,61269-0735-14,NDC,outpatient,14,GR,7.54,5.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,48433-0202-30,NDC,outpatient,30,ML,5.08,3.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,99999-0002-15,NDC,outpatient,30,ML,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINOCYCLINE HCL 50 MG ORAL CAPS,RX-5111,CDM,S5000,HCPCS,259,RC,00591-5694-60,NDC,outpatient,1,UN,1.26,0.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-11,NDC,outpatient,1,UN,2.48,1.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-01,NDC,outpatient,1,UN,2.48,1.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-01,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-11,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,00591-5642-01,NDC,outpatient,1,UN,1.01,0.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-05,NDC,outpatient,5,ML,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-59,NDC,outpatient,5,ML,4.7,3.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00054-0237-49,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-94,NDC,outpatient,5,ML,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-62,NDC,outpatient,5,ML,4.7,3.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,99999-0002-19,NDC,outpatient,5,ML,2.14,1.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-25,NDC,outpatient,1,UN,2.1,1.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-24,NDC,outpatient,1,UN,3.2,2.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MORPHINE SULFATE 10 MG RE SUPP,RX-5180,CDM,S5000,HCPCS,259,RC,00574-7112-12,NDC,outpatient,1,UN,19.66,13.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-95,NDC,outpatient,1,UN,11.38,7.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-25,NDC,outpatient,1,UN,11.38,7.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,69097-0868-07,NDC,outpatient,1,UN,1.13,0.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,00904-7071-07,NDC,outpatient,1,UN,9.11,6.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,65162-0188-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,65162-0189-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65862-0522-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65162-0190-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,63739-0403-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-05,NDC,outpatient,1,UN,3.09,2.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-07,NDC,outpatient,1,UN,3.09,2.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,S5000,HCPCS,259,RC,24208-0790-62,NDC,outpatient,10,ML,150.86,105.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIACIN 100 MG ORAL TABS,RX-5539,CDM,S5000,HCPCS,259,RC,80681-0057-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NIFEDIPINE 10 MG ORAL CAPS,RX-5558,CDM,S5000,HCPCS,259,RC,23155-0194-01,NDC,outpatient,1,UN,1.98,1.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAPS,RX-5595,CDM,S5000,HCPCS,259,RC,57664-0232-88,NDC,outpatient,1,UN,3.41,2.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,72888-0138-01,NDC,outpatient,1,UN,1.43,1.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,68462-0638-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,00071-0417-24,NDC,outpatient,1,UN,3.05,2.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-45,NDC,outpatient,0.75,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-25,NDC,outpatient,0.75,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-11,NDC,outpatient,0.75,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-35,NDC,outpatient,0.75,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,S5000,HCPCS,259,RC,00281-0326-08,NDC,outpatient,1,GR,9.96,6.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-11,NDC,outpatient,1,UN,1.89,1.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-01,NDC,outpatient,1,UN,1.89,1.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,51672-1289-01,NDC,outpatient,15,GR,18.83,13.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,00713-0678-15,NDC,outpatient,15,GR,53.4,37.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,45802-0059-35,NDC,outpatient,15,GR,17.03,11.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,00472-0166-15,NDC,outpatient,15,GR,61.35,42.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,45802-0048-35,NDC,outpatient,15,GR,13.29,9.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-05,NDC,outpatient,5,ML,4.74,3.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-70,NDC,outpatient,5,ML,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,99999-0003-91,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-00,NDC,outpatient,5,ML,4.74,3.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-1045-16,NDC,outpatient,5,ML,4.21,2.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-10,NDC,outpatient,5,ML,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,S5000,HCPCS,259,RC,51672-1263-01,NDC,outpatient,15,GR,15.02,10.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,S5000,HCPCS,259,RC,51672-1272-01,NDC,outpatient,15,GR,22.37,15.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ORA-PLUS ORAL LIQD,RX-5851,CDM,S5000,HCPCS,259,RC,00574-0303-16,NDC,outpatient,473,ML,130.96,91.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ORA-SWEET SF ORAL SYRP,RX-5853,CDM,S5000,HCPCS,259,RC,00574-0302-16,NDC,outpatient,473,ML,130.96,91.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-11,NDC,outpatient,1,UN,8.63,6.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,00228-2067-10,NDC,outpatient,1,UN,3.24,2.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-01,NDC,outpatient,1,UN,8.63,6.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-11,NDC,outpatient,1,UN,9.09,6.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-01,NDC,outpatient,1,UN,9.09,6.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-01,NDC,outpatient,1,UN,1.85,1.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-11,NDC,outpatient,1,UN,1.85,1.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,00904-7027-61,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-23,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-62,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-07,NDC,outpatient,2,ML,78.96,55.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-05,NDC,outpatient,2,ML,78.96,55.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-01,NDC,outpatient,2,ML,69.91,48.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-10,NDC,outpatient,2,ML,69.91,48.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,00517-4002-25,NDC,outpatient,2,ML,103.84,72.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-95,NDC,outpatient,1,UN,142.02,99.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-94,NDC,outpatient,1,UN,142.02,99.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,00093-4127-73,NDC,outpatient,100,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,99999-0002-88,NDC,outpatient,10,ML,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENICILLIN V POTASSIUM 250 MG ORAL TABS,RX-6092,CDM,S5000,HCPCS,259,RC,57237-0040-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00093-1174-01,NDC,outpatient,1,UN,1.67,1.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00143-9836-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PERPHENAZINE 2 MG ORAL TABS,RX-6157,CDM,S5000,HCPCS,259,RC,00904-6599-61,NDC,outpatient,1,UN,2.75,1.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PERPHENAZINE 8 MG ORAL TABS,RX-6159,CDM,S5000,HCPCS,259,RC,00904-6601-61,NDC,outpatient,1,UN,5.02,3.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENAZOPYRIDINE HCL 100 MG ORAL TABS,RX-6193,CDM,S5000,HCPCS,259,RC,65162-0681-10,NDC,outpatient,1,UN,1.61,1.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,99999-0002-30,NDC,outpatient,5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-05,NDC,outpatient,5,ML,7.01,4.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,54932-0501-81,NDC,outpatient,473,ML,75.78,53.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,13517-0107-16,NDC,outpatient,473,ML,307.31,215.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,16571-0675-16,NDC,outpatient,473,ML,82.09,57.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-50,NDC,outpatient,5,ML,7.01,4.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,16571-0673-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,00904-6575-61,NDC,outpatient,1,UN,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,S5000,HCPCS,259,RC,00225-0800-47,NDC,outpatient,15,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,S5000,HCPCS,259,RC,00225-0805-47,NDC,outpatient,15,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,S5000,HCPCS,259,RC,00225-0810-47,NDC,outpatient,15,ML,15.09,10.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYLEPHRINE HCL 2.5 % OP SOLN,RX-6246,CDM,S5000,HCPCS,259,RC,70756-0629-25,NDC,outpatient,2,ML,146.94,102.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-66,NDC,outpatient,4,ML,13.48,9.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-62,NDC,outpatient,4,ML,13.48,9.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,57664-0808-88,NDC,outpatient,1,UN,1.19,0.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,65862-0692-01,NDC,outpatient,1,UN,1.74,1.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,S5000,HCPCS,259,RC,61314-0203-15,NDC,outpatient,15,ML,342.03,239.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,70069-0191-01,NDC,outpatient,15,ML,140.98,98.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,61314-0204-15,NDC,outpatient,15,ML,351.44,246.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,S5000,HCPCS,259,RC,61314-0206-15,NDC,outpatient,15,ML,326.81,228.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PIROXICAM 10 MG ORAL CAPS,RX-6310,CDM,S5000,HCPCS,259,RC,42571-0176-01,NDC,outpatient,1,UN,3.12,2.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,00087-0402-03,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,99999-0001-68,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,S5000,HCPCS,250,RC,55150-0234-10,NDC,outpatient,1,UN,16.13,11.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-01,NDC,outpatient,20,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,51754-2001-04,NDC,outpatient,20,ML,18.07,12.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-11,NDC,outpatient,20,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POVIDONE-IODINE 10 % EX SOLN,RX-6458,CDM,S5000,HCPCS,259,RC,52380-1905-00,NDC,outpatient,59,ML,4.73,3.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-20,NDC,outpatient,1,UN,6.21,4.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-01,NDC,outpatient,1,UN,6.21,4.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-01,NDC,outpatient,1,UN,5.34,3.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-11,NDC,outpatient,1,UN,5.34,3.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-01,NDC,outpatient,1,UN,14.76,10.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-20,NDC,outpatient,1,UN,14.76,10.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,11980-0180-05,NDC,outpatient,5,ML,534.23,373.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,60758-0119-05,NDC,outpatient,5,ML,106.58,74.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,61314-0637-05,NDC,outpatient,5,ML,113.48,79.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,59651-0484-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-8739-25,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-4741-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00904-6923-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00054-0017-20,NDC,outpatient,1,UN,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00603-5338-21,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-8740-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-4742-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,64380-0785-07,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00054-0018-20,NDC,outpatient,1,UN,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00904-7127-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,59746-0175-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,00054-8724-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-20,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-25,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,10135-0779-01,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,59651-0489-01,NDC,outpatient,1,UN,1.61,1.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASCORBIC ACID 500 MG/ML IJ SOLN,RX-654,CDM,S5000,HCPCS,250,RC,67157-0101-51,NDC,outpatient,50,ML,1099.15,769.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-15,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-11,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROBENECID 500 MG ORAL TABS,RX-6561,CDM,S5000,HCPCS,259,RC,00591-5347-01,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,99999-0002-39,NDC,outpatient,5,ML,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,27808-0065-02,NDC,outpatient,2.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,61314-0016-01,NDC,outpatient,15,ML,111.21,77.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,24208-0730-06,NDC,outpatient,15,ML,110.61,77.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00054-3727-63,NDC,outpatient,500,ML,209.15,146.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-40,NDC,outpatient,5,ML,10.08,7.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-05,NDC,outpatient,5,ML,10.08,7.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,69238-2077-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,00378-0182-01,NDC,outpatient,1,UN,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-11,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,00603-5484-21,NDC,outpatient,1,UN,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-01,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,00228-2348-10,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,67253-0651-10,NDC,outpatient,1,UN,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-5053-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-6990-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,33342-0447-11,NDC,outpatient,1,UN,19.28,13.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,70954-0484-10,NDC,outpatient,1,UN,17.43,12.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,10135-0735-60,NDC,outpatient,1,UN,15.09,10.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
QUININE SULFATE 324 MG ORAL CAPS,RX-6781,CDM,S5000,HCPCS,259,RC,50742-0238-30,NDC,outpatient,1,UN,2.82,1.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-80,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,63739-0434-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,66553-0002-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,57896-0901-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,66553-0001-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 325 MG ORAL TBEC,RX-685,CDM,S5000,HCPCS,259,RC,57896-0921-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,63739-0212-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00536-1234-41,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00904-6783-70,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ASPIRIN 300 MG RE SUPP,RX-693,CDM,S5000,HCPCS,259,RC,00574-7034-12,NDC,outpatient,1,UN,4.58,3.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN DETEMIR 100 UNIT/ML SC SOLN,RX-70261,CDM,S5000,HCPCS,259,RC,00169-3687-12,NDC,outpatient,10,ML,388.27,271.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-99,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,49348-0356-25,NDC,outpatient,44,ML,5.88,4.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,00904-3865-75,NDC,outpatient,44,ML,3.33,2.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAMADOL HCL ER 200 MG ORAL TB24,RX-70353,CDM,S5000,HCPCS,259,RC,68180-0698-06,NDC,outpatient,1,UN,19.84,13.888,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-11,NDC,outpatient,1,UN,5.08,3.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-15,NDC,outpatient,1,UN,5.07,3.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,68462-0319-60,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-21,NDC,outpatient,1,UN,5.08,3.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-11,NDC,outpatient,1,UN,5.07,3.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LUBIPROSTONE 24 MCG ORAL CAPS,RX-70472,CDM,S5000,HCPCS,259,RC,00254-3029-02,NDC,outpatient,1,UN,4.45,3.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00536-1183-99,NDC,outpatient,9.9,ML,45.6,31.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00054-3270-99,NDC,outpatient,16,GR,32.12,22.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,S5000,HCPCS,259,RC,00002-7511-01,NDC,outpatient,10,ML,211.82,148.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,61570-0131-55,NDC,outpatient,50,GR,30.49,21.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-40,NDC,outpatient,400,GR,153.08,107.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-50,NDC,outpatient,50,GR,55.18,38.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,00904-7206-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,49348-0188-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,69618-0033-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,49348-0740-27,NDC,outpatient,0.6,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,00536-1303-75,NDC,outpatient,0.3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,99999-0003-45,NDC,outpatient,0.6,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-73,NDC,outpatient,20,ML,14.91,10.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-83,NDC,outpatient,20,ML,14.91,10.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-04,NDC,outpatient,100,ML,36.05,25.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-00,NDC,outpatient,100,ML,36.05,25.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-12,NDC,outpatient,5,ML,19.45,13.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,63323-0083-05,NDC,outpatient,5,ML,33.6,23.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-14,NDC,outpatient,10,ML,57.94,40.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-24,NDC,outpatient,10,ML,57.94,40.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-02,NDC,outpatient,5,ML,19.45,13.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-24,NDC,outpatient,50,ML,85.67,59.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-14,NDC,outpatient,50,ML,85.67,59.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-14,NDC,outpatient,10,ML,71.78,50.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,69374-0214-50,NDC,outpatient,50,ML,48.95,34.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-14,NDC,outpatient,50,ML,35.83,25.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-14,NDC,outpatient,50,ML,54.74,38.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-24,NDC,outpatient,50,ML,54.74,38.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-24,NDC,outpatient,10,ML,71.78,50.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-04,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,63323-0089-50,NDC,outpatient,50,ML,24.7,17.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-22,NDC,outpatient,50,ML,35.83,25.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-01,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,76329-3352-01,NDC,outpatient,50,ML,66.31,46.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM BICARBONATE 650 MG ORAL TABS,RX-7313,CDM,S5000,HCPCS,259,RC,66553-0008-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,00338-0054-03,NDC,outpatient,500,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,99999-0004-11,NDC,outpatient,250,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-61,NDC,outpatient,100,ML,55.63,38.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-02,NDC,outpatient,100,ML,55.63,38.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,76204-0300-03,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-03,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-33,NDC,outpatient,3,ML,1.13,0.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,00487-9003-30,NDC,outpatient,4,ML,2.44,1.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,50190-0142-63,NDC,outpatient,4,ML,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-10,NDC,outpatient,1,UN,1.03,0.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,00223-1760-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-25,NDC,outpatient,1,UN,1.03,0.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,S5000,HCPCS,259,RC,24208-0385-55,NDC,outpatient,3.5,GR,68.8,48.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,S5000,HCPCS,259,RC,00536-1254-94,NDC,outpatient,15,ML,15.76,11.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM HYPOCHLORITE 5 % SOLN,RX-7343,CDM,S5000,HCPCS,259,RC,SH000-4343-01,NDC,outpatient,4000,ML,17.8,12.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM POLYSTYRENE SULFONATE ORAL POWD,RX-7356,CDM,S5000,HCPCS,259,RC,11534-0166-15,NDC,outpatient,15,GR,55.61,38.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFACETAMIDE SODIUM 10 % OP SOLN,RX-7359,CDM,S5000,HCPCS,259,RC,24208-0670-04,NDC,outpatient,15,ML,213.67,149.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,S5000,HCPCS,259,RC,60219-1749-03,NDC,outpatient,5,ML,103.02,72.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,63629-1061-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,00904-6927-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-24,NDC,outpatient,50,ML,8.74,6.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-10,NDC,outpatient,10,ML,4.22,2.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-50,NDC,outpatient,50,ML,8.74,6.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-01,NDC,outpatient,10,ML,4.79,3.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-25,NDC,outpatient,10,ML,4.79,3.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0004-04,NDC,outpatient,1000,ML,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0003-47,NDC,outpatient,3000,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
STOMAHESIVE PASTE PSTE,RX-7493,CDM,S5000,HCPCS,259,RC,68455-0106-90,NDC,outpatient,56.7,GR,38.61,27.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFADIAZINE 500 MG ORAL TABS,RX-7554,CDM,S5000,HCPCS,259,RC,42806-0757-60,NDC,outpatient,1,UN,65.91,46.137,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-10,NDC,outpatient,10,ML,27.51,19.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-01,NDC,outpatient,10,ML,28.26,19.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-03,NDC,outpatient,10,ML,28.26,19.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-01,NDC,outpatient,10,ML,27.51,19.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-65,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-15,NDC,outpatient,1,UN,1.12,0.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-11,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-11,NDC,outpatient,1,UN,1.12,0.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFASALAZINE 500 MG ORAL TABS,RX-7562,CDM,S5000,HCPCS,259,RC,59762-5000-05,NDC,outpatient,1,UN,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,00013-0102-50,NDC,outpatient,1,UN,8.65,6.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,59762-0104-05,NDC,outpatient,1,UN,1.47,1.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VARENICLINE TARTRATE 0.5 MG ORAL TABS,RX-76444,CDM,S5000,HCPCS,259,RC,49884-0155-76,NDC,outpatient,1,UN,6.79,4.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-11,NDC,outpatient,1,UN,43.68,30.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-21,NDC,outpatient,1,UN,43.68,30.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,S5000,HCPCS,259,RC,24208-0539-20,NDC,outpatient,1,UN,349.11,244.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,00436-0672-16,NDC,outpatient,473,ML,52.63,36.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,39328-0064-12,NDC,outpatient,473,ML,44.21,30.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-01,NDC,outpatient,15,ML,8.75,6.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-16,NDC,outpatient,7.5,ML,2.05,1.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-15,NDC,outpatient,15,ML,19.43,13.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-15,NDC,outpatient,15,ML,3.54,2.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-40,NDC,outpatient,15,ML,19.43,13.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-50,NDC,outpatient,15,ML,8.75,6.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN D3 25 MCG (1000 UT) ORAL TABS,RX-76997,CDM,S5000,HCPCS,259,RC,20555-0033-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TANNIC ACID POWD,RX-7715,CDM,S5000,HCPCS,259,RC,,,outpatient,20,GR,9.26,6.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-01,NDC,outpatient,10,ML,230.25,161.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-05,NDC,outpatient,10,ML,230.25,161.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-01,NDC,outpatient,1,UN,78.54,54.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-28,NDC,outpatient,1,UN,78.54,54.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-01,NDC,outpatient,1,UN,78.54,54.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-31,NDC,outpatient,1,UN,78.53,54.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-28,NDC,outpatient,1,UN,78.54,54.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,00121-1576-10,NDC,outpatient,10,ML,13.35,9.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,99999-0001-27,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,68682-0920-64,NDC,outpatient,15,ML,325.88,228.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,00065-0741-14,NDC,outpatient,4,ML,54.08,37.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TETRACYCLINE HCL 250 MG ORAL CAPS,RX-7796,CDM,S5000,HCPCS,259,RC,23155-0766-01,NDC,outpatient,1,UN,2.97,2.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-44,NDC,outpatient,15,ML,40.12,28.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-15,NDC,outpatient,15,ML,35.25,24.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-71,NDC,outpatient,15,ML,40.12,28.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-40,NDC,outpatient,15,ML,35.25,24.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THERA ORAL TABS,RX-7825,CDM,S5000,HCPCS,259,RC,00904-0539-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THERA-DERM EX LOTN,RX-7831,CDM,S5000,HCPCS,259,RC,00904-4299-09,NDC,outpatient,236,ML,8.41,5.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MESALAMINE 1.2 G ORAL TBEC,RX-78310,CDM,S5000,HCPCS,259,RC,00527-3012-48,NDC,outpatient,1,UN,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00395-0413-96,NDC,outpatient,177,ML,11.82,8.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,49348-0011-34,NDC,outpatient,177,ML,6.31,4.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00904-2533-21,NDC,outpatient,177,ML,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,99999-0002-04,NDC,outpatient,5,ML,1.78,1.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-40,NDC,outpatient,5,ML,11.06,7.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-05,NDC,outpatient,5,ML,11.06,7.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THYROID 30 MG ORAL TABS,RX-7944,CDM,S5000,HCPCS,259,RC,62559-0741-01,NDC,outpatient,1,UN,2.88,2.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,00904-0722-36,NDC,outpatient,14.18,GR,4.36,3.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,49348-0155-29,NDC,outpatient,15,GR,8.88,6.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,S5000,HCPCS,259,RC,00536-1329-26,NDC,outpatient,45,GR,7.41,5.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-11,NDC,outpatient,1,UN,1.77,1.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,68382-0807-01,NDC,outpatient,1,UN,1.31,0.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-15,NDC,outpatient,1,UN,1.77,1.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,68382-0805-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,00904-6868-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,50111-0560-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,60505-2653-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,S5000,HCPCS,259,RC,00168-0003-80,NDC,outpatient,80,GR,21.72,15.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,67877-0251-80,NDC,outpatient,80,GR,39.16,27.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,45802-0064-36,NDC,outpatient,80,GR,11.04,7.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,S5000,HCPCS,259,RC,45802-0065-35,NDC,outpatient,15,GR,20.23,14.161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN,RX-8115,CDM,S5000,HCPCS,259,RC,70752-0129-05,NDC,outpatient,60,ML,126.03,88.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,60432-0561-61,NDC,outpatient,60,ML,66.75,46.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,00713-0676-53,NDC,outpatient,60,ML,73.43,51.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.025 % EX OINT,RX-8117,CDM,S5000,HCPCS,259,RC,00168-0005-80,NDC,outpatient,80,GR,21.01,14.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00168-0006-80,NDC,outpatient,80,GR,22.79,15.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00713-0228-80,NDC,outpatient,80,GR,37.03,25.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,45802-0055-36,NDC,outpatient,80,GR,19.58,13.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,51672-1284-08,NDC,outpatient,80,GR,43.44,30.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,S5000,HCPCS,259,RC,33342-0332-15,NDC,outpatient,15,GR,28.77,20.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,S5000,HCPCS,259,RC,64980-0320-05,NDC,outpatient,5,GR,139.78,97.846,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIVALPROEX SODIUM ER 500 MG ORAL TB24,RX-81426,CDM,S5000,HCPCS,259,RC,00904-7182-45,NDC,outpatient,1,UN,11.3,7.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00186-0372-28,NDC,outpatient,6.9,GR,250.86,175.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00310-7372-20,NDC,outpatient,10.2,GR,973.53,681.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00310-7370-20,NDC,outpatient,10.2,GR,1011.48,708.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00186-0370-28,NDC,outpatient,6,GR,250.85,175.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIFLUOPERAZINE HCL 1 MG ORAL TABS,RX-8161,CDM,S5000,HCPCS,259,RC,00781-8028-01,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIFLUOPERAZINE HCL 5 MG ORAL TABS,RX-8164,CDM,S5000,HCPCS,259,RC,00781-8034-01,NDC,outpatient,1,UN,4.68,3.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,00591-5335-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,69452-0241-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TRIHEXYPHENIDYL HCL 5 MG ORAL TABS,RX-8167,CDM,S5000,HCPCS,259,RC,70954-0211-10,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,68180-0407-03,NDC,outpatient,6.25,ML,50.07,35.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,99999-0002-91,NDC,outpatient,6.25,ML,120.07,84.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-15,NDC,outpatient,37.5,GR,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0627-63,NDC,outpatient,31,GR,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-30,NDC,outpatient,37.5,GR,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0070-30,NDC,outpatient,37.5,GR,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0626-53,NDC,outpatient,31,GR,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,50190-0141-23,NDC,outpatient,4,ML,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0207-60,NDC,outpatient,4,ML,3.01,2.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0307-60,NDC,outpatient,4,ML,1.2,0.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THROMBI-GEL 40 EX PADS,RX-82259,CDM,S5000,HCPCS,259,RC,60793-0908-04,NDC,outpatient,1,UN,254.02,177.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TROPICAMIDE 1 % OP SOLN,RX-8250,CDM,S5000,HCPCS,259,RC,70069-0121-01,NDC,outpatient,15,ML,25.3,17.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-15,NDC,outpatient,1,UN,93.94,65.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-61,NDC,outpatient,1,UN,93.94,65.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-03,NDC,outpatient,1,UN,24.46,17.122,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-11,NDC,outpatient,1,UN,24.46,17.122,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-78,NDC,outpatient,0.1,ML,35.98,25.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-21,NDC,outpatient,0.1,ML,35.98,25.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
UNNA-FLEX ELASTIC UNNA BOOT EX MISC,RX-8371,CDM,S5000,HCPCS,250,RC,68455-0107-63,NDC,outpatient,1,UN,44.16,30.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00832-0310-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,69452-0150-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00591-4012-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT,RX-849,CDM,S5000,HCPCS,259,RC,24208-0785-55,NDC,outpatient,3.5,GR,70.76,49.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-02,NDC,outpatient,2,ML,15.45,10.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-04,NDC,outpatient,2,ML,15.45,10.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,70710-1643-07,NDC,outpatient,2,ML,44.5,31.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-01,NDC,outpatient,2,ML,15.45,10.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL 120 MG ORAL TABS,RX-8528,CDM,S5000,HCPCS,259,RC,23155-0486-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL 40 MG ORAL TABS,RX-8529,CDM,S5000,HCPCS,259,RC,23155-0059-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VERAPAMIL HCL 80 MG ORAL TABS,RX-8530,CDM,S5000,HCPCS,259,RC,23155-0026-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,70677-0013-01,NDC,outpatient,28.4,GR,10.49,7.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,49348-0029-72,NDC,outpatient,30,GR,11.49,8.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,S5000,HCPCS,259,RC,00501-3798-05,NDC,outpatient,14.2,GR,20.67,14.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,S5000,HCPCS,259,RC,24208-0555-55,NDC,outpatient,3.5,GR,22.88,16.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00527-1330-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00904-6475-61,NDC,outpatient,1,UN,1.6,1.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,63739-0479-10,NDC,outpatient,1,UN,1.74,1.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN E 100 UNITS ORAL CAPS,RX-8698,CDM,S5000,HCPCS,259,RC,80681-0134-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,00536-1352-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-14,NDC,outpatient,5,GR,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-05,NDC,outpatient,5,GR,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-01,NDC,outpatient,1,UN,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-11,NDC,outpatient,1,UN,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-01,NDC,outpatient,1,UN,1.29,0.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-11,NDC,outpatient,1,UN,1.29,0.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0705-05,NDC,outpatient,1,UN,217.65,152.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0205-05,NDC,outpatient,1,UN,228.51,159.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,S5000,HCPCS,259,RC,35181-7303-32,NDC,outpatient,25,GR,146.52,102.564,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,00023-9211-05,NDC,outpatient,5,ML,838.92,587.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,82182-0455-05,NDC,outpatient,5,ML,356.54,249.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZEPAM 2.5 MG RE GEL,RX-87865,CDM,S5000,HCPCS,259,RC,68682-0650-20,NDC,outpatient,1,UN,430.63,301.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZEPAM 10 MG RE GEL,RX-87867,CDM,S5000,HCPCS,259,RC,68682-0652-20,NDC,outpatient,1,UN,622.96,436.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DIAZEPAM 20 MG RE GEL,RX-87869,CDM,S5000,HCPCS,259,RC,68682-0655-20,NDC,outpatient,1,UN,601.24,420.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,49502-0605-61,NDC,outpatient,2,ML,20.29,14.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-32,NDC,outpatient,2,ML,38.15,26.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-93,NDC,outpatient,2,ML,38.15,26.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-60,NDC,outpatient,2,ML,11.64,8.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-06,NDC,outpatient,2,ML,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-19,NDC,outpatient,2,ML,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-01,NDC,outpatient,2,ML,18.21,12.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-60,NDC,outpatient,2,ML,18.21,12.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-44,NDC,outpatient,2,ML,11.64,8.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RALTEGRAVIR POTASSIUM 400 MG ORAL TABS,RX-88608,CDM,S5000,HCPCS,259,RC,00006-0227-61,NDC,outpatient,1,UN,143.66,100.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-01,NDC,outpatient,10,ML,63.68,44.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-11,NDC,outpatient,10,ML,63.68,44.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,31722-0630-31,NDC,outpatient,1,UN,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,00004-0802-85,NDC,outpatient,1,UN,57.3,40.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OSELTAMIVIR PHOSPHATE 45 MG ORAL CAPS,RX-88705,CDM,S5000,HCPCS,259,RC,00004-0801-85,NDC,outpatient,1,UN,57.3,40.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,00536-1316-98,NDC,outpatient,454,GR,22.23,15.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,75834-0170-01,NDC,outpatient,28.4,GR,13.53,9.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-01,NDC,outpatient,10,ML,75.92,53.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-25,NDC,outpatient,10,ML,75.92,53.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-25,NDC,outpatient,5,ML,189.8,132.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-01,NDC,outpatient,5,ML,189.8,132.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,00904-6707-82,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-64,NDC,outpatient,1,UN,6.38,4.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-59,NDC,outpatient,1,UN,6.38,4.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
NEBIVOLOL HCL 5 MG ORAL TABS,RX-89284,CDM,S5000,HCPCS,259,RC,00904-7189-04,NDC,outpatient,1,UN,7.99,5.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-07,NDC,outpatient,1,UN,32.67,22.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-10,NDC,outpatient,1,UN,22.14,15.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-11,NDC,outpatient,1,UN,5.16,3.612,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-15,NDC,outpatient,1,UN,5.16,3.612,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,57074-0001-86,NDC,outpatient,60,GR,9.35,6.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,30103-0040-00,NDC,outpatient,60,GR,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-05,NDC,outpatient,5,ML,4.72,3.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-59,NDC,outpatient,5,ML,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-62,NDC,outpatient,5,ML,2.76,1.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,99999-0004-23,NDC,outpatient,5,ML,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-61,NDC,outpatient,5,ML,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-00,NDC,outpatient,5,ML,4.72,3.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,59676-0570-01,NDC,outpatient,1,UN,53.89,37.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,60219-1721-07,NDC,outpatient,1,UN,36.43,25.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-62,NDC,outpatient,1,UN,1.51,1.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-23,NDC,outpatient,1,UN,1.51,1.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,S5000,HCPCS,250,RC,00338-0322-01,NDC,outpatient,1,UN,281.38,196.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-11,NDC,outpatient,1,UN,4.66,3.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-65,NDC,outpatient,1,UN,4.66,3.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00527-1695-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00904-6938-06,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,10702-0253-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACETIC ACID 0.25 % IR SOLN,RX-8963,CDM,S5000,HCPCS,250,RC,00338-0656-04,NDC,outpatient,1000,ML,13.35,9.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,45802-0044-75,NDC,outpatient,5,GR,210.13,147.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,00187-0994-45,NDC,outpatient,5,GR,822.36,575.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,00904-5789-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,60505-0042-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,31722-0681-47,NDC,outpatient,473,ML,244.17,170.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,99999-0004-02,NDC,outpatient,5,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,00472-0082-16,NDC,outpatient,473,ML,1582.85,1107.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-01,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-11,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-73,NDC,outpatient,30,ML,11.09,7.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,99999-0002-58,NDC,outpatient,30,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00121-1761-30,NDC,outpatient,30,ML,7.21,5.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-62,NDC,outpatient,30,ML,11.09,7.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,57896-0629-12,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-01,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-30,NDC,outpatient,30,ML,1.7,1.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMINOCAPROIC ACID 500 MG ORAL TABS,RX-9063,CDM,S5000,HCPCS,259,RC,69680-0115-30,NDC,outpatient,1,UN,26.56,18.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,63739-0051-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00904-6993-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMLODIPINE BESYLATE 2.5 MG ORAL TABS,RX-9070,CDM,S5000,HCPCS,259,RC,00904-6369-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,68382-0122-16,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,00904-6370-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,64850-0502-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,42806-0341-01,NDC,outpatient,1,UN,1.52,1.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00008-1211-14,NDC,outpatient,1,UN,5.76,4.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00591-3659-30,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,51991-0311-90,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ROPINIROLE HCL ER 2 MG ORAL TB24,RX-92015,CDM,S5000,HCPCS,259,RC,55111-0659-30,NDC,outpatient,1,UN,2.69,1.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-11,NDC,outpatient,1,UN,2.09,1.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-15,NDC,outpatient,1,UN,2.09,1.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,S5000,HCPCS,259,RC,61314-0245-01,NDC,outpatient,5,ML,147.74,103.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10135-0623-01,NDC,outpatient,1,UN,2.28,1.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10702-0013-01,NDC,outpatient,1,UN,1.58,1.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
MOUTH KOTE MT SOLN,RX-92764,CDM,S5000,HCPCS,259,RC,50930-0098-02,NDC,outpatient,59,ML,21.53,15.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BROMOCRIPTINE MESYLATE 2.5 MG ORAL TABS,RX-9297,CDM,S5000,HCPCS,259,RC,00574-0106-03,NDC,outpatient,1,UN,3.28,2.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,42799-0119-01,NDC,outpatient,1,UN,1.43,1.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-11,NDC,outpatient,1,UN,5.55,3.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-15,NDC,outpatient,1,UN,5.55,3.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-11,NDC,outpatient,1,UN,3.09,2.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-01,NDC,outpatient,1,UN,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,69238-1490-01,NDC,outpatient,1,UN,1.61,1.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-11,NDC,outpatient,1,UN,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-05,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-15,NDC,outpatient,1,UN,3.09,2.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-01,NDC,outpatient,50,ML,49.4,34.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-57,NDC,outpatient,50,ML,49.4,34.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL 100 MG ORAL TABS,RX-9321,CDM,S5000,HCPCS,259,RC,00904-6636-61,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-11,NDC,outpatient,1,UN,3.85,2.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-15,NDC,outpatient,1,UN,2.99,2.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-01,NDC,outpatient,1,UN,3.85,2.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-11,NDC,outpatient,1,UN,2.99,2.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00093-0053-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00904-7122-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,23155-0662-01,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,69452-0207-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-33,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,00904-6412-92,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-32,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,66553-0004-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SORBITOL 70 % SOLN,RX-93927,CDM,S5000,HCPCS,259,RC,46287-0500-30,NDC,outpatient,30,ML,9.48,6.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-49,NDC,outpatient,3,ML,1.42,0.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-30,NDC,outpatient,3,ML,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-60,NDC,outpatient,3,ML,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-93,NDC,outpatient,3,ML,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-03,NDC,outpatient,3,ML,1.13,0.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-01,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,76204-0600-01,NDC,outpatient,3,ML,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-31,NDC,outpatient,3,ML,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-48,NDC,outpatient,3,ML,1.42,0.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAPTOPRIL 12.5 MG ORAL TABS,RX-9401,CDM,S5000,HCPCS,259,RC,00904-7105-61,NDC,outpatient,1,UN,6.29,4.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CAPTOPRIL 25 MG ORAL TABS,RX-9402,CDM,S5000,HCPCS,259,RC,00904-7106-61,NDC,outpatient,1,UN,5.2,3.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBIDOPA-LEVODOPA 10-100 MG ORAL TABS,RX-9406,CDM,S5000,HCPCS,259,RC,00093-9701-01,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,00093-9702-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-08,NDC,outpatient,1,ML,319.49,223.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-05,NDC,outpatient,1,ML,319.49,223.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,S5000,HCPCS,259,RC,00904-6255-49,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,63044-0622-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,60258-0162-01,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFACLOR 250 MG ORAL CAPS,RX-9430,CDM,S5000,HCPCS,259,RC,61442-0171-30,NDC,outpatient,1,UN,8.1,5.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-08,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,65862-0085-50,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,16714-0388-01,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-01,NDC,outpatient,1,UN,2.36,1.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,65862-0096-20,NDC,outpatient,1,UN,14.53,10.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,00781-5439-20,NDC,outpatient,1,UN,12.33,8.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,67877-0215-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,16714-0400-02,NDC,outpatient,1,UN,3.64,2.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,65862-0699-60,NDC,outpatient,1,UN,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-11,NDC,outpatient,1,UN,1.49,1.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-01,NDC,outpatient,1,UN,1.3,0.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-11,NDC,outpatient,1,UN,1.3,0.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,67877-0220-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-15,NDC,outpatient,1,UN,1.49,1.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-15,NDC,outpatient,15,ML,6.55,4.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-19,NDC,outpatient,15,ML,6.15,4.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,5.99,4.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,1,ML,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,54838-0011-50,NDC,outpatient,50,ML,14.02,9.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,99999-0003-94,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,61314-0656-05,NDC,outpatient,5,ML,15.4,10.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,69315-0308-05,NDC,outpatient,5,ML,62.3,43.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,65862-0225-60,NDC,outpatient,1,UN,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,00527-1931-06,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,59762-3743-01,NDC,outpatient,30,GR,208.26,145.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,00168-0202-30,NDC,outpatient,30,GR,207.33,145.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,51672-1258-02,NDC,outpatient,30,GR,31.11,21.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,69238-1532-05,NDC,outpatient,15,GR,19.83,13.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,21922-0017-05,NDC,outpatient,30,GR,42.19,29.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,51672-1259-02,NDC,outpatient,30,GR,43.53,30.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-25,NDC,outpatient,1,UN,36.81,25.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-95,NDC,outpatient,1,UN,36.81,25.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-11,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,16729-0137-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,43547-0407-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-11,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00054-4146-22,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00574-0107-70,NDC,outpatient,1,UN,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-01,NDC,outpatient,1,UN,4.21,2.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-01,NDC,outpatient,1,UN,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-11,NDC,outpatient,1,UN,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-20,NDC,outpatient,1,UN,4.21,2.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-01,NDC,outpatient,1,UN,2.14,1.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-20,NDC,outpatient,1,UN,2.14,1.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,S5000,HCPCS,259,RC,50484-0010-30,NDC,outpatient,30,GR,1218.46,852.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,S5000,HCPCS,259,RC,61314-0237-10,NDC,outpatient,10,ML,27.77,19.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,68462-0678-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-60,NDC,outpatient,1,UN,53.28,37.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-35,NDC,outpatient,1,UN,48.43,33.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,51991-0349-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-11,NDC,outpatient,1,UN,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,00131-2478-60,NDC,outpatient,1,UN,83.29,58.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-57,NDC,outpatient,1,UN,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,31722-0813-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,S5000,HCPCS,259,RC,00065-0397-02,NDC,outpatient,2,ML,180.67,126.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,S5000,HCPCS,259,RC,00065-0359-02,NDC,outpatient,2,ML,144.23,100.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,60505-0134-00,NDC,outpatient,1,UN,46.97,32.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-61,NDC,outpatient,1,UN,74.28,51.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-15,NDC,outpatient,1,UN,74.28,51.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-15,NDC,outpatient,1,UN,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-61,NDC,outpatient,1,UN,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-25,NDC,outpatient,1,UN,18.44,12.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-95,NDC,outpatient,1,UN,18.44,12.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,S5000,HCPCS,250,RC,42023-0123-06,NDC,outpatient,1,UN,288.51,201.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00115-4411-01,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00904-7211-04,NDC,outpatient,1,UN,4.53,3.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,55150-0173-01,NDC,outpatient,0.5,ML,17.69,12.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,63323-0273-01,NDC,outpatient,0.5,ML,24.66,17.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,60432-0608-16,NDC,outpatient,10,ML,3.48,2.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,99999-0002-38,NDC,outpatient,10,ML,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,99999-0001-87,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-00,NDC,outpatient,10,ML,7.53,5.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-10,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00904-7135-72,NDC,outpatient,10,ML,6.5,4.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-10,NDC,outpatient,10,ML,7.53,5.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-34,NDC,outpatient,118,ML,8.93,6.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-04,NDC,outpatient,118,ML,17.33,12.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-10,NDC,outpatient,10,ML,1.7,1.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
TOLVAPTAN 15 MG ORAL TABS,RX-97893,CDM,S5000,HCPCS,259,RC,59148-0020-50,NDC,outpatient,1,UN,1428.57,999.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS ORAL CPEP,RX-98034,CDM,S5000,HCPCS,259,RC,00032-0046-70,NDC,outpatient,1,UN,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-1224-01,NDC,outpatient,1,UN,33.86,23.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-2636-01,NDC,outpatient,1,UN,33.86,23.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN,RX-9809,CDM,S5000,HCPCS,250,RC,00264-7622-00,NDC,outpatient,1000,ML,51.6,36.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-9812,CDM,S5000,HCPCS,250,RC,00338-0077-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE-SODIUM CHLORIDE 5-0.33 % IV SOLN,RX-9813,CDM,S5000,HCPCS,250,RC,00264-7614-10,NDC,outpatient,500,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DRONEDARONE HCL 400 MG ORAL TABS,RX-98329,CDM,S5000,HCPCS,259,RC,00024-4142-60,NDC,outpatient,1,UN,53.6,37.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRASUGREL HCL 5 MG ORAL TABS,RX-98372,CDM,S5000,HCPCS,259,RC,60505-4642-03,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,1,UN,4.12,2.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,1,UN,2.9,2.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,1,UN,1,0.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZOIN COMPOUND EX TINC,RX-987,CDM,S5000,HCPCS,259,RC,00395-0243-92,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DINOPROSTONE 0.5 MG/3GM VA GEL,RX-9874,CDM,S5000,HCPCS,259,RC,00009-3359-01,NDC,outpatient,3,GR,1932.45,1352.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,42806-0714-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,00904-7153-61,NDC,outpatient,1,UN,1.32,0.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,69452-0143-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,64380-0712-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-25,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-95,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,00904-5522-61,NDC,outpatient,1,UN,2.36,1.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,60505-0095-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,16729-0213-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,00904-5524-61,NDC,outpatient,1,UN,2.28,1.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,68180-0657-01,NDC,outpatient,20,ML,27.06,18.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,99999-0002-89,NDC,outpatient,20,ML,27.06,18.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,S5000,HCPCS,259,RC,51672-1303-01,NDC,outpatient,15,GR,32.65,22.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,23155-0772-01,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,43547-0547-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENALAPRIL MALEATE 2.5 MG ORAL TABS,RX-9925,CDM,S5000,HCPCS,259,RC,16714-0442-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-01,NDC,outpatient,2,ML,34.39,24.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-10,NDC,outpatient,2,ML,34.39,24.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,99999-0002-24,NDC,outpatient,0.6,ML,13.98,9.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,42799-0217-01,NDC,outpatient,0.6,ML,13.98,9.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GLYCERIN (LAXATIVE) 1 G RE SUPP,RX-99417,CDM,S5000,HCPCS,259,RC,58980-0409-12,NDC,outpatient,1,UN,2.17,1.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0146-19,NDC,outpatient,1,UN,133.73,93.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0162-88,NDC,outpatient,1,UN,133.64,93.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ESTROGENS CONJUGATED 0.3 MG ORAL TABS,RX-9973,CDM,S5000,HCPCS,259,RC,00046-1100-81,NDC,outpatient,1,UN,28.4,19.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,67457-0297-50,NDC,outpatient,1,UN,2098.98,1469.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,42023-0157-01,NDC,outpatient,1,UN,1563.3,1094.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-11,NDC,outpatient,1,UN,1.82,1.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-01,NDC,outpatient,1,UN,1.82,1.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETHACRYNIC ACID 25 MG ORAL TABS,RX-9980,CDM,S5000,HCPCS,259,RC,69238-1126-01,NDC,outpatient,1,UN,8.7,6.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETHAMBUTOL HCL 400 MG ORAL TABS,RX-9983,CDM,S5000,HCPCS,259,RC,68850-0012-02,NDC,outpatient,1,UN,3.21,2.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,60505-3927-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,24979-0533-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
GUANFACINE HCL ER 2 MG ORAL TB24,RX-99836,CDM,S5000,HCPCS,259,RC,62332-0746-31,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,23155-0532-01,NDC,outpatient,1,UN,5.34,3.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,64380-0878-06,NDC,outpatient,1,UN,1.63,1.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-01,NDC,outpatient,1,UN,1.62,1.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-11,NDC,outpatient,1,UN,1.62,1.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,60505-0039-01,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,62559-0250-01,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
ETODOLAC 300 MG ORAL CAPS,RX-9998,CDM,S5000,HCPCS,259,RC,62559-0251-01,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List
HC Crisis Intervention Mental Health Services- per Diem,PX-90000001,CDM,S9485,HCPCS,900,RC,,,outpatient,,,1627,1138.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,651.9389,365.2615,1249.536,percent of total billed charges,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,outpatient,,,10370,7259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,4155.259,399.86,9291.52,percent of total billed charges,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,outpatient,,,7029,4920.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2816.5203,399.86,9291.52,percent of total billed charges,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions 
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,838.94559,399.86,2223.8905,percent of total billed charges,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3992.7552,other,Non-Reimbursable List
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3992.7552,other,Non-Reimbursable List
Bilateral procedure,,,,,,,,,,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,525.9295,1261.6,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,808.0705,1938.4,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,731.3655,1754.4,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1108.2205,2658.4,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,594.6305,2483,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,444.5555,1066.4,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,398.5325,956,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1337.0015,3207.2,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1215.941,2916.8,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,672.0025,1612,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1604.135,3848,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.205,72,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.491,94.4,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,25.3685,90.4,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.96,64,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.7355,63.2,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,59.9415,213.6,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.205,72,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.309,225.6,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.166,214.4,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.5335,226.4,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.9825,228,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,64.4315,229.6,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,68.9215,245.6,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,94.9635,338.4,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,98.331,350.4,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,118.7605,423.2,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,118.7605,423.2,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,183.192,652.8,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,871.958,3107.2,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1098.0295,3912.8,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1176.829,4193.6,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1227.117,4372.8,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,149.7415,533.6,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.2485,282.4,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,73.4115,261.6,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,87.555,312,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,158.7215,565.6,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,32.328,122.0544,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,58.819,222.0712,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,61.064,230.5472,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,68.697,259.3656,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,84.6365,319.5452,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,105.7395,399.2196,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.005,415.324,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,210.8055,795.8964,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.756,74.5888,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,21.3275,80.522,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.246,91.5408,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,28.736,108.4928,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,43.3285,163.5868,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,43.7775,165.282,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,50.5125,190.71,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.1465,302.5932,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.1465,302.5932,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.1465,302.5932,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,83.963,317.0024,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,88.902,335.6496,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,90.249,340.7352,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,91.8205,346.6684,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,93.841,354.2968,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,93.6165,353.4492,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.127,378.0296,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,101.2495,382.2676,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,104.617,394.9816,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,104.617,394.9816,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,105.515,398.372,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.556,413.6288,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,115.842,437.3616,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,116.5155,439.9044,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,117.4135,443.2948,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,121.4545,458.5516,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,121.4545,458.5516,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,124.822,471.2656,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,151.313,571.2824,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.803,588.2344,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.803,588.2344,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.803,588.2344,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,157.8235,595.8628,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,161.4155,609.4244,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,162.089,611.9672,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,164.1095,619.5956,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,171.7425,648.414,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.212,657.7376,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.212,657.7376,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,189.7025,716.222,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,189.7025,716.222,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,189.7025,716.222,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,200.9275,758.602,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,200.9275,758.602,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,185.6615,700.9652,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,210.8055,795.8964,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,219.7855,829.8004,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,354.9345,1340.0556,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,354.9345,1340.0556,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,255.032,962.8736,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,284.8905,1075.6044,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,296.1155,1117.9844,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,314.0755,1185.7924,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,316.096,1193.4208,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,455.0615,1718.0852,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,498.1655,1880.8244,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,584.149,2205.4552,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,660.7035,2494.4868,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1249.3425,4716.894,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1237.444,4671.9712,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,924.94,3492.112,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1237.444,4671.9712,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,302.8505,1143.4124,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.7555,33.0564,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,277.931,1049.3288,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,249.8685,943.3788,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,423.6315,1599.4212,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,246.2765,929.8172,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,337.648,1274.7904,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,71.6155,270.3844,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,103.719,391.5912,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,241.7865,912.8652,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.107,411.9336,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.3515,378.8772,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,299.034,1129.0032,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,66.6765,251.7372,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,120.5565,455.1612,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,126.8425,478.894,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,93.6165,353.4492,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,92.494,349.2112,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.1295,585.6916,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,113.597,428.8856,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,95.188,359.3824,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,133.353,503.4744,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,118.7605,448.3804,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,203.397,767.9256,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.476,549.2448,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,222.255,839.124,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,194.1925,733.174,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,97.2085,367.0108,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,88.453,333.9544,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,136.047,513.6456,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,157.15,593.32,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,495.0225,1868.958,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,299.932,1132.3936,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,245.603,927.2744,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,266.706,1006.9488,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,259.073,978.1304,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,259.073,978.1304,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,176.2325,665.366,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.8855,660.2804,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,267.3795,1009.4916,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,220.6835,833.1908,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,102.5965,387.3532,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,105.7395,399.2196,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,104.3925,394.134,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,184.7635,697.5748,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,138.9655,524.6644,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,178.4775,673.842,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,162.089,611.9672,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,55.0025,207.662,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,214.173,808.6104,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,259.073,978.1304,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,111.5765,421.2572,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,56.3495,212.7476,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,91.596,345.8208,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.3515,378.8772,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.5955,304.2884,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,70.044,264.4512,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,70.044,264.4512,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,139.639,527.2072,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,123.924,467.8752,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,274.1145,1034.9196,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,846.814,3197.1472,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,438.673,1656.2104,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,854.447,3225.9656,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,148.3945,560.2636,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.965,483.132,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.965,483.132,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,759.9325,2869.126,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,715.0325,2699.606,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,85.31,322.088,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.8855,660.2804,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,74.085,279.708,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,85.759,323.7832,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.576,379.7248,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.1885,400.9148,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.699,425.4952,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,147.721,557.7208,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,148.3945,560.2636,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,157.8235,595.8628,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,167.2525,631.462,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,176.2325,665.366,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,202.2745,763.6876,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,205.4175,775.554,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,250.7665,946.7692,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,574.72,2169.856,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,574.72,2169.856,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,667.663,2520.7624,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,675.9695,2552.1236,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,675.9695,2552.1236,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,710.5425,2682.654,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,767.341,2897.0968,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,777.219,2934.3912,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1481.0265,5591.6172,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,147.721,557.7208,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,147.721,557.7208,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,276.584,1044.2432,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,392.875,1483.3,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,882.9585,3333.6108,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,923.593,3487.0264,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1001.4945,3781.1436,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,104.617,394.9816,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,667.663,2520.7624,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,667.663,2520.7624,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,667.663,2520.7624,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,238.419,900.1512,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,238.419,900.1512,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,238.419,900.1512,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,324.4025,1224.782,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.576,379.7248,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,77.9015,294.1172,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,239.0925,902.694,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.2485,299.2028,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,317.2185,1197.6588,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,289.605,1093.404,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,289.605,1093.404,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,479.3075,1809.626,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,167.2525,631.462,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,58.819,222.0712,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,58.819,222.0712,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.2485,299.2028,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,288.707,1090.0136,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.7005,550.0924,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,170.171,642.4808,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,238.6435,900.9988,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,245.3785,926.4268,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,273.2165,1031.5292,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,304.1975,1148.498,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,313.851,1184.9448,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,330.913,1249.3624,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,336.5255,1270.5524,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,398.0385,1502.7948,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,355.8325,1343.446,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,367.282,1386.6736,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,392.6505,1482.4524,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.413,401.7624,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.413,401.7624,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.413,401.7624,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,73.636,278.0128,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.107,411.9336,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,398.0385,1502.7948,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.803,588.2344,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.413,401.7624,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.6375,402.61,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,383.895,1449.396,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,297.9115,1124.7652,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,297.9115,1124.7652,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,291.85,1101.88,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.184,27.1232,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.879,120.3592,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,35.2465,133.0732,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.124,128.8352,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,46.696,176.3008,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,13.47,50.856,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,16.8375,63.57,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,13.47,50.856,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,16.8375,63.57,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2255,83.9124,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.43,118.664,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,30.981,116.9688,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,35.6955,134.7684,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,157.15,593.32,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,190.825,720.46,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,373.119,1408.7112,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,213.275,805.22,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,656.438,2478.3824,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,269.4,1017.12,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,956.819,3612.4712,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2057.767,7769.1016,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,269.4,1017.12,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,841.6505,3177.6524,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1202.422,4539.7456,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2164.4045,8171.7116,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,5.6125,21.19,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.939,18.6472,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,5.1635,19.4948,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,6.286,23.7328,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,6.5105,24.5804,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.4085,27.9708,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.531,32.2088,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,336.75,1271.4,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.6745,6652,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.7405,482.2844,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.7405,482.2844,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,6.5105,24.5804,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.5715,163,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.6535,163,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,38.3895,163,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9291.52,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6297.984,,
Heart Transplant Or Implant Of Heart Assist System With McC,1,MS-DRG,,,,,,,inpatient,,,509415.58,356590.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,209573.79,,,209573.79,7771.48,570763.9296,case rate,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,495073.43,346551.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,137408.02,,,137408.02,7771.48,434261.5728,case rate,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,347238.19,243066.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,85826.2,,,85826.2,7771.48,286312.0824,case rate,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,111379.6,77965.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,36295.61,,,36295.61,7771.48,109336.4384,case rate,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,80508.95,56356.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,32499.2,,,32499.2,7771.48,90620.608,case rate,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,64638.3,45246.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,42109.97,,,42109.97,7771.48,123186.8824,case rate,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,31748.36,22223.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23840.61,,,23840.61,7771.48,68016.116,case rate,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,38853.43,27197.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17054.54,,,17054.54,7771.48,45091.4528,case rate,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,36305.14,25413.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12449.94,,,12449.94,7771.48,32329.1856,case rate,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,66447.77,46513.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28757.78,,,28757.78,7771.48,78796.564,case rate,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,67076.27,46953.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16909.83,,,16909.83,7771.48,53661.016,case rate,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,60360.78,42252.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13394.15,,,13394.15,7771.48,48288.624,case rate,
Extracranial Procedures With McC,37,MS-DRG,,,,,,,inpatient,,,89958.63,62971.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23693.73,,,23693.73,7771.48,71966.904,case rate,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,41578.78,29105.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11991.21,,,11991.21,7771.48,33263.024,case rate,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,33795.18,23656.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8241.11,,,8241.11,7771.48,27036.144,case rate,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,68215.86,47751.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17011.13,,,17011.13,7771.48,54572.688,case rate,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,26930.4,18851.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9882.1,,,9882.1,7771.48,30377.7624,case rate,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,21358.75,14951.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7549.41,,,7549.41,7123.143125,22105.9976,case rate,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,44783.08,31348.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15825.97,,,15825.97,7771.48,50741.056,case rate,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,47305.96,33114.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9146.98,,,9146.98,7771.48,37844.768,case rate,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,15006.39,10504.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12565.7,,,12565.7,5004.631065,37401.2648,case rate,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,24159.04,16911.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8150.67,,,8150.67,7771.48,24793.004,case rate,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,28159.44,19711.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6624.72,,,6624.72,6624.72,22527.552,case rate,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,89978.5,62984.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20897.25,,,20897.25,7771.48,71982.8,case rate,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,41764.16,29234.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14378.17,,,14378.17,7771.48,36086.1312,case rate,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,29171.68,20420.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13841.3,,,13841.3,7771.48,40307.1224,case rate,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20113.63,14079.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7367.07,,,7367.07,6707.895605,20608.488,case rate,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,15729.11,11010.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5143.64,,,5143.64,5143.64,13947.7112,case rate,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,46442.5,32509.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10307.54,,,10307.54,7771.48,37154,case rate,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,28051.55,19636.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6429.37,,,6429.37,6429.37,22441.24,case rate,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17263.03,12084.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5687.74,,,5687.74,5687.74,16215.2528,case rate,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,34983.65,24488.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12129.41,,,12129.41,7771.48,35233.0168,case rate,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,19683.37,13778.359,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7313.53,,,7313.53,6564.403895,21354.2032,case rate,
Nonspecific Cerebrovascular Disorders Without Cc/McC,72,MS-DRG,,,,,,,inpatient,,,12084.89,8459.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5579.93,,,5579.93,4030.310815,15200.0264,case rate,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,16388.09,11471.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10486.97,,,10486.97,5465.428015,31318.012,case rate,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,28055.14,19638.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7368.52,,,7368.52,7368.52,22444.112,case rate,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,26116.94,18281.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7097.19,,,7097.19,7097.19,20893.552,case rate,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,23235.5,16264.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11083.89,,,11083.89,7749.03925,31332.1968,case rate,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,15869.98,11108.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6866.39,,,6866.39,5292.63833,20219.4192,case rate,
Hypertensive Encephalopathy Without Cc/McC,79,MS-DRG,,,,,,,inpatient,,,15211.5,10648.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5258.68,,,5258.68,5073.03525,13510.0088,case rate,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,53186.54,37230.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15136.44,,,15136.44,7771.48,42549.232,case rate,
Nontraumatic Stupor And Coma Without McC,81,MS-DRG,,,,,,,inpatient,,,72271.24,50589.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5585.72,,,5585.72,5585.72,57816.992,case rate,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,28572.47,20000.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16338.23,,,16338.23,7771.48,47014.5064,case rate,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,30376.08,21263.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9707.72,,,9707.72,7771.48,28173.0392,case rate,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,15324.04,10726.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6542.24,,,6542.24,5110.56734,19372.384,case rate,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,40898.43,28628.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16687.7,,,16687.7,7771.48,45916.1976,case rate,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,13317.55,9322.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9209.93,,,9209.93,4441.402925,26578.2624,case rate,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,24255.02,16978.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6241.25,,,6241.25,6241.25,19404.016,case rate,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,42230.83,29561.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11930.43,,,11930.43,7771.48,36937.2192,case rate,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,30155.68,21108.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7134.82,,,7134.82,7134.82,24124.544,case rate,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,16152.97,11307.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5653.01,,,5653.01,5387.015495,15994.3752,case rate,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,56481.63,39537.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26286.9,,,26286.9,7771.48,73931.1776,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,49973.83,34981.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27151.52,,,27151.52,7771.48,72642.3872,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,15617.77,10932.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15273.18,,,15273.18,5208.526295,43954.6424,case rate,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC,99,MS-DRG,,,,,,,inpatient,,,27081.74,18957.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10110.01,,,10110.01,7771.48,28231.8048,case rate,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,34012.87,23809.009,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13556.23,,,13556.23,7771.48,40228.0928,case rate,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,18803.33,13162.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6417.79,,,6417.79,6270.910555,18675.3024,case rate,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,27377.14,19163.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8333,,,8333,7771.48,23494.0816,case rate,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,23893.76,16725.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5992.35,,,5992.35,5992.35,19115.008,case rate,
Acute Major Eye Infections With Cc/McC,121,MS-DRG,,,,,,,inpatient,,,20815.14,14570.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8600.71,,,8600.71,6941.84919,23569.0584,case rate,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,28026.78,19618.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5537.24,,,5537.24,5537.24,22421.424,case rate,
Other Disorders Of The Eye With McC Or Thrombolytic Agent,124,MS-DRG,,,,,,,inpatient,,,12298.33,8608.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10120.86,,,10120.86,4101.493055,26420.2032,case rate,
Other Disorders Of The Eye Without McC,125,MS-DRG,,,,,,,inpatient,,,18740.93,13118.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6044.44,,,6044.44,6044.44,16731.9848,case rate,
Mouth Procedures With Cc/McC,137,MS-DRG,,,,,,,inpatient,,,29533.69,20673.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10625.89,,,10625.89,7771.48,28339.204,case rate,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,44941.05,31458.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21444.25,,,21444.25,7771.48,66905.6488,case rate,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,9316.44,6521.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12665.55,,,12665.55,3107.03274,35595.7424,case rate,
Ear- Nose- Mouth And Throat Malignancy With McC,146,MS-DRG,,,,,,,inpatient,,,13156.92,9209.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14710.27,,,14710.27,4387.83282,46483.5896,case rate,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,13619.01,9533.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5321.63,,,5321.63,4541.939835,15147.34,case rate,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,12866.36,9006.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7791.79,,,7791.79,4290.93106,22993.5608,case rate,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,16420.88,11494.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5141.47,,,5141.47,5141.47,14421.8888,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,12009,8406.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11160.59,,,11160.59,4005.0015,32953.3168,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,39912.51,27938.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6561.05,,,6561.05,6561.05,31930.008,case rate,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,11067.63,7747.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4757.99,,,4757.99,3691.054605,13625.5136,case rate,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,27223.03,19056.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6432.99,,,6432.99,6432.99,21778.424,case rate,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,2839.79,1987.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4744.97,,,4744.97,947.069965,13366.1344,case rate,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,115551.53,80886.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,35895.49,,,35895.49,7771.48,93394.7496,case rate,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,85038.13,59526.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19095.64,,,19095.64,7771.48,68030.504,case rate,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,69826.08,48878.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13845.64,,,13845.64,7771.48,55860.864,case rate,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,55683.12,38978.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27431.53,,,27431.53,7771.48,78036.664,case rate,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,45649.7,31954.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13471.57,,,13471.57,7771.48,37024.3544,case rate,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,47015.57,32910.899,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9905.97,,,9905.97,7771.48,37612.456,case rate,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,20842.72,14589.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11172.89,,,11172.89,6951.04712,28554.0024,case rate,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,18317.47,12822.229,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6415.62,,,6415.62,6108.876245,16505.028,case rate,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,31259.62,21881.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13351.47,,,13351.47,7771.48,32756.756,case rate,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,20969.38,14678.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8725.16,,,8725.16,6993.28823,20103.9144,case rate,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20162.41,14113.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6302.75,,,6302.75,6302.75,16129.928,case rate,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,37050.11,25935.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12573.66,,,12573.66,7771.48,35415.3928,case rate,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,30930.47,21651.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8110.15,,,8110.15,7771.48,24744.376,case rate,
Respiratory Neoplasms Without Cc/McC,182,MS-DRG,,,,,,,inpatient,,,24638.57,17246.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5697.87,,,5697.87,5697.87,19710.856,case rate,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,35855.45,25098.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11255.37,,,11255.37,7771.48,32163.0208,case rate,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,22588.59,15812.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7520.46,,,7520.46,7520.46,21641.952,case rate,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,25741.06,18018.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11165.65,,,11165.65,7771.48,32017.12,case rate,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,11443.72,8010.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7468.37,,,7468.37,3816.48062,20343.0296,case rate,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,21611.05,15127.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8861.91,,,8861.91,7207.285175,25076.7,case rate,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,22710.76,15897.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8131.85,,,8131.85,7574.03846,22762.5512,case rate,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,17567.6,12297.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6389.57,,,6389.57,5858.7946,17408.8024,case rate,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,13024.23,9116.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5027.87,,,5027.87,4343.580705,13114.8608,case rate,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,25981.01,18186.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9483.43,,,9483.43,7771.48,26703.8992,case rate,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,18230.9,12761.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6244.14,,,6244.14,6080.00515,16616.48,case rate,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,12094.06,8465.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4811.53,,,4811.53,4033.36901,12620.4192,case rate,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25422.94,17796.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12561.36,,,12561.36,7771.48,38181.4288,case rate,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,23032.67,16122.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7275.91,,,7275.91,7275.91,20059.3336,case rate,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,22301.78,15611.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12933.98,,,12933.98,7437.64363,35770.0128,case rate,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,31940.04,22358.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7778.04,,,7778.04,7771.48,25552.032,case rate,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,17352.2,12146.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5133.51,,,5133.51,5133.51,13881.76,case rate,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,17596.96,12317.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6986.49,,,6986.49,5868.58616,19589.2088,case rate,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,12229.54,8560.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5104.57,,,5104.57,4078.55159,14109.8232,case rate,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,30544.64,21381.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5734.05,,,5734.05,5734.05,24435.712,case rate,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,23745.99,16622.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12172.1,,,12172.1,7771.48,38252.3528,case rate,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,17630.01,12341.007,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6397.53,,,6397.53,5879.608335,18355.1312,case rate,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,173078.09,121154.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,41432.74,,,41432.74,7771.48,138462.472,case rate,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,53859.21,37701.447,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18394.53,,,18394.53,7771.48,54390.6024,case rate,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,354301.39,248010.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,80731.76,,,80731.76,7771.48,283441.112,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC,216,MS-DRG,,,,,,,inpatient,,,299760.69,209832.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,75465.84,,,75465.84,7771.48,239808.552,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,inpatient,,,204620.11,143234.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,46977.94,,,46977.94,7771.48,163696.088,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC,219,MS-DRG,,,,,,,inpatient,,,208854.44,146198.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,58281.79,,,58281.79,7771.48,167083.552,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,inpatient,,,154365.68,108055.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,39070.38,,,39070.38,7771.48,123492.544,case rate,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,181781.45,127247.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,32937.67,,,32937.67,7771.48,145425.16,case rate,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,228758.84,160131.188,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,44970.12,,,44970.12,7771.48,183007.072,case rate,
Other Cardiothoracic Procedures Without McC,229,MS-DRG,,,,,,,inpatient,,,95347.28,66743.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28854.74,,,28854.74,7771.48,76277.824,case rate,
Coronary Bypass With Ptca With McC,231,MS-DRG,,,,,,,inpatient,,,220697.29,154488.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,61429.91,,,61429.91,7771.48,176557.832,case rate,
Coronary Bypass With Ptca Without McC,232,MS-DRG,,,,,,,inpatient,,,203083.55,142158.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,42676.5,,,42676.5,7771.48,162466.84,case rate,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,193515.4,135460.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,56383.22,,,56383.22,7771.48,158379.3712,case rate,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,165546.93,115882.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,38473.46,,,38473.46,7771.48,132437.544,case rate,
Coronary Bypass Without Cardiac Catheterization With McC,235,MS-DRG,,,,,,,inpatient,,,145342.16,101739.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,43630.85,,,43630.85,7771.48,119229.3232,case rate,
Coronary Bypass Without Cardiac Catheterization Without McC,236,MS-DRG,,,,,,,inpatient,,,130227.12,91158.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,29526.18,,,29526.18,7771.48,104181.696,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,39344.02,27540.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,34792.82,,,34792.82,7771.48,102059.636,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,41409.42,28986.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20186.01,,,20186.01,7771.48,59008.768,case rate,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC,241,MS-DRG,,,,,,,inpatient,,,19499.72,13649.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11514.4,,,11514.4,6503.15662,30594.5872,case rate,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,76706.54,53694.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26933.74,,,26933.74,7771.48,68735.488,case rate,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,63602.84,44521.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18324.35,,,18324.35,7771.48,50882.272,case rate,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,60755.43,42528.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14946.15,,,14946.15,7771.48,48604.344,case rate,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,109531.23,76671.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,39172.4,,,39172.4,7771.48,99020.036,case rate,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC,250,MS-DRG,,,,,,,inpatient,,,42609.28,29826.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18253.44,,,18253.44,7771.48,46864.5528,case rate,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,52812.94,36969.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12009.3,,,12009.3,7771.48,42250.352,case rate,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,100566.7,70396.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,24026.56,,,24026.56,7771.48,80453.36,case rate,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,72499.37,50749.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19200.55,,,19200.55,7771.48,57999.496,case rate,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,68903.94,48232.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13092.44,,,13092.44,7771.48,55123.152,case rate,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13134.86,9194.402,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11888.47,,,11888.47,4380.47581,34319.1104,case rate,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,20863.13,14604.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8400.29,,,8400.29,6957.853855,18073.4616,case rate,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,44827.64,31379.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15340.47,,,15340.47,7771.48,35862.112,case rate,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,130030.35,91021.245,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25933.08,,,25933.08,7771.48,104024.28,case rate,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,49670.67,34769.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14407.83,,,14407.83,7771.48,39736.536,case rate,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC,262,MS-DRG,,,,,,,inpatient,,,58341.51,40839.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12358.77,,,12358.77,7771.48,46673.208,case rate,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,49042.27,34329.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23499.1,,,23499.1,7771.48,70820.6536,case rate,
Aicd Lead Procedures,265,MS-DRG,,,,,,,inpatient,,,64208.05,44945.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,24330.45,,,24330.45,7771.48,72279.6616,case rate,
Endovascular Cardiac Valve Replacement And Supplement Procedures With McC,266,MS-DRG,,,,,,,inpatient,,,134751.65,94326.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,51351.01,,,51351.01,7771.48,121389.4656,case rate,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC,267,MS-DRG,,,,,,,inpatient,,,133372.27,93360.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,40524.7,,,40524.7,7771.48,106697.816,case rate,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,241728.99,169210.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,50319.24,,,50319.24,7771.48,193383.192,case rate,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,132639.05,92847.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31217.81,,,31217.81,7771.48,106111.24,case rate,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,135782.35,95047.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,37490.9,,,37490.9,7771.48,108625.88,case rate,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,140000.81,98000.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25791.27,,,25791.27,7771.48,112000.648,case rate,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,151532.98,106073.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19454.52,,,19454.52,7771.48,121226.384,case rate,
Percutaneous And Other Intracardiac Procedures With McC,273,MS-DRG,,,,,,,inpatient,,,102782.81,71947.967,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27763.64,,,27763.64,7771.48,82226.248,case rate,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,82201.95,57541.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23771.15,,,23771.15,7771.48,65761.56,case rate,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31041.23,21728.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11766.19,,,11766.19,7771.48,33263.356,case rate,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,26543.44,18580.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6744.11,,,6744.11,6744.11,21234.752,case rate,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,23815.3,16670.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5249.28,,,5249.28,5249.28,19052.24,case rate,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,19212.47,13448.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13491.11,,,13491.11,6407.358745,39624.2256,case rate,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,10954.07,7667.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5312.22,,,5312.22,3653.182345,15013.5976,case rate,
Acute Myocardial Infarction- Expired Without Cc/McC,285,MS-DRG,,,,,,,inpatient,,,7163.26,5014.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,3591.65,,,3591.65,2388.94721,11374.1832,case rate,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,38892.53,27224.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16019.88,,,16019.88,7771.48,44850.3112,case rate,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,30727.74,21509.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8320.7,,,8320.7,7771.48,24582.192,case rate,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,28457.96,19920.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19398.08,,,19398.08,7771.48,55347.0632,case rate,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,19767.12,13836.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11884.85,,,11884.85,6592.33452,31948.2224,case rate,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,20727.01,14508.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9701.93,,,9701.93,6912.457835,26442.4936,case rate,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,15225.15,10657.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6476.4,,,6476.4,5077.587525,17453.3832,case rate,
Heart Failure And Shock Without Cc/McC,293,MS-DRG,,,,,,,inpatient,,,10124.22,7086.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4721.82,,,4721.82,3376.42737,11124.936,case rate,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,25950.27,18165.189,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11539,,,11539,7771.48,33198.5112,case rate,
Cardiac Arrest- Unexplained With Cc,297,MS-DRG,,,,,,,inpatient,,,10642.36,7449.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5098.06,,,5098.06,3549.22706,14273.9616,case rate,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,22073.95,15451.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11080.28,,,11080.28,7361.662325,32781.0728,case rate,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,21942.88,15360.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7540.72,,,7540.72,7317.95048,21692.612,case rate,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,24649.73,17254.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5372.28,,,5372.28,5372.28,19719.784,case rate,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,9953.04,6967.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7911.9,,,7911.9,3319.33884,23571.0848,case rate,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16791.27,11753.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4894.02,,,4894.02,4894.02,13625.5136,case rate,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,37676.15,26373.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7927.09,,,7927.09,7771.48,30140.92,case rate,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,16488.7,11542.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5343.34,,,5343.34,5343.34,15212.1848,case rate,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,22172.6,15520.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10879.86,,,10879.86,7394.5621,30343.3136,case rate,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,15582.95,10908.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6283.21,,,6283.21,5196.913825,18770.5432,case rate,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,19410.63,13587.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8677.4,,,8677.4,6473.445105,24438.384,case rate,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,14290.45,10003.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5422.2,,,5422.2,4765.865075,14981.1752,case rate,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,11407.4,7985.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4040.24,,,4040.24,3804.3679,11337.708,case rate,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,11897.35,8328.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5043.07,,,5043.07,3967.766225,14154.404,case rate,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,16541.17,11578.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6057.47,,,6057.47,5516.480195,17656.0232,case rate,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,15084.64,10559.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5215.27,,,5215.27,5030.72744,14454.3112,case rate,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,31164.15,21814.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15074.21,,,15074.21,7771.48,43636.4976,case rate,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,18201.8,12741.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7055.95,,,7055.95,6070.3003,19500.0472,case rate,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,10045.09,7031.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5422.92,,,5422.92,3350.037515,13832.2064,case rate,
Other Endovascular Cardiac Valve Procedures With McC,319,MS-DRG,,,,,,,inpatient,,,92577.92,64804.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31226.5,,,31226.5,7771.48,89009.62,case rate,
Other Endovascular Cardiac Valve Procedures Without McC,320,MS-DRG,,,,,,,inpatient,,,39673.91,27771.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17681.12,,,17681.12,7771.48,46903.0544,case rate,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,64991.97,45494.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,38909.76,,,38909.76,7771.48,102914.7768,case rate,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,59110.49,41377.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18881.47,,,18881.47,7771.48,49203.0184,case rate,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,49561.22,34692.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12050.54,,,12050.54,7771.48,39648.976,case rate,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,78913.19,55239.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,35093.81,,,35093.81,7771.48,93046.2088,case rate,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,69586.46,48710.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18370.66,,,18370.66,7771.48,55669.168,case rate,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,57546.85,40282.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12373.24,,,12373.24,7771.48,46037.48,case rate,
Rectal Resection Without Cc/McC,334,MS-DRG,,,,,,,inpatient,,,106215.45,74350.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11643.19,,,11643.19,7771.48,84972.36,case rate,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,73034.84,51124.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28148.56,,,28148.56,7771.48,73434.7096,case rate,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,43630.89,30541.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16517.67,,,16517.67,7771.48,42805.6736,case rate,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,37370.19,26159.133,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11812.5,,,11812.5,7771.48,31105.24,case rate,
Minor Small And Large Bowel Procedures With McC,344,MS-DRG,,,,,,,inpatient,,,23852.76,16696.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20265.6,,,20265.6,7771.48,54599.3216,case rate,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,15908.61,11136.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11415.27,,,11415.27,5305.521435,30177.1488,case rate,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,21216.99,14851.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9225.12,,,9225.12,7075.866165,25232.7328,case rate,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,44922.74,31445.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17810.64,,,17810.64,7771.48,47956.7824,case rate,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,23475.59,16432.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9712.79,,,9712.79,7771.48,25508.3232,case rate,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,34354.1,24047.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10783.63,,,10783.63,7771.48,30491.2408,case rate,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,42230.08,29561.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7980.64,,,7980.64,7771.48,33784.064,case rate,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,312395.2,218676.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21766.22,,,21766.22,7771.48,249916.16,case rate,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,44235.04,30964.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12900.7,,,12900.7,7771.48,35388.032,case rate,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,51507.45,36055.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9834.34,,,9834.34,7771.48,41205.96,case rate,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,70735.47,49514.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31049.95,,,31049.95,7771.48,86434.0656,case rate,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,77577.93,54304.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16306.4,,,16306.4,7771.48,62062.344,case rate,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,27080.24,18956.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9688.19,,,9688.19,7771.48,27457.72,case rate,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,23431.55,16402.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14053.3,,,14053.3,7771.48,33838.8536,case rate,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,31489.94,22042.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7791.07,,,7791.07,7771.48,25191.952,case rate,
Major Esophageal Disorders Without Cc/McC,370,MS-DRG,,,,,,,inpatient,,,29793.71,20855.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5409.18,,,5409.18,5409.18,23834.968,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,37215.27,26050.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12504.92,,,12504.92,7771.48,35427.5512,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,24764.87,17335.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7435.09,,,7435.09,7435.09,20857.7352,case rate,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,19807.89,13865.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5379.51,,,5379.51,5379.51,15846.312,case rate,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,38795.7,27156.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14962.06,,,14962.06,7771.48,42787.436,case rate,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,40108.1,28075.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8717.92,,,8717.92,7771.48,32086.48,case rate,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,8031.54,5622.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6477.12,,,6477.12,2678.51859,17891.0856,case rate,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,38252.31,26776.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13015.74,,,13015.74,7771.48,36841.9784,case rate,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,30659.48,21461.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7186.19,,,7186.19,7186.19,24527.584,case rate,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,17080.5,11956.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4609.67,,,4609.67,4609.67,13664.4,case rate,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33361.1,23352.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13624.96,,,13624.96,7771.48,38994.0152,case rate,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,34876.59,24413.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7667.34,,,7667.34,7667.34,27901.272,case rate,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,23295.58,16306.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6456.86,,,6456.86,6456.86,18636.464,case rate,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,19010.83,13307.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11714.82,,,11714.82,6340.111805,32922.9208,case rate,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,17687.57,12381.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7188.36,,,7188.36,5898.804595,20109.9936,case rate,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12268.03,8587.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5162.45,,,5162.45,4091.388005,13582.9592,case rate,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,35037.99,24526.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10938.46,,,10938.46,7771.48,29788.08,case rate,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,19193.48,13435.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5946.04,,,5946.04,5946.04,16245.6488,case rate,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12403.72,8682.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4215.34,,,4215.34,4136.64062,11086.4344,case rate,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,23697.98,16588.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9003.72,,,9003.72,7771.48,26037.2136,case rate,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16680.62,11676.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5530.73,,,5530.73,5530.73,15811.9992,case rate,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,35226.46,24658.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11964.44,,,11964.44,7771.48,33555.1576,case rate,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,21027.93,14719.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6791.14,,,6791.14,6791.14,19074.5032,case rate,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,19292.51,13504.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4700.83,,,4700.83,4700.83,15434.008,case rate,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,43167.44,30217.208,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20816.22,,,20816.22,7771.48,56905.3648,case rate,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,37981.98,26587.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15310.09,,,15310.09,7771.48,43275.7984,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC,408,MS-DRG,,,,,,,inpatient,,,66496.81,46547.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27129.09,,,27129.09,7771.48,70946.2904,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,54723.42,38306.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15297.79,,,15297.79,7771.48,43778.736,case rate,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC,410,MS-DRG,,,,,,,inpatient,,,49332.9,34533.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11328.45,,,11328.45,7771.48,39466.32,case rate,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,inpatient,,,94854.82,66398.374,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16465.58,,,16465.58,7771.48,75883.856,case rate,
Cholecystectomy Except By Laparoscope Without C.D.E. With McC,414,MS-DRG,,,,,,,inpatient,,,158479.92,110935.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26231.91,,,26231.91,7771.48,126783.936,case rate,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/McC,416,MS-DRG,,,,,,,inpatient,,,36054.28,25237.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10290.17,,,10290.17,7771.48,28843.424,case rate,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,57775.9,40443.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17534.97,,,17534.97,7771.48,48157.396,case rate,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,45650.74,31955.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12214.06,,,12214.06,7771.48,36520.592,case rate,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,40583.9,28408.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9515.98,,,9515.98,7771.48,32467.12,case rate,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,43141.15,30198.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25425.88,,,25425.88,7771.48,71515.7088,case rate,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,126455.95,88519.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,30236.69,,,30236.69,7771.48,101164.76,case rate,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,37750.2,26425.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13617.73,,,13617.73,7771.48,39699.2024,case rate,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,22206.74,15544.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7441.6,,,7441.6,7405.94779,21676.4008,case rate,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,9888.24,6921.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4483.05,,,4483.05,3297.72804,14111.8496,case rate,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41222.48,28855.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12682.19,,,12682.19,7771.48,36971.668,case rate,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,21857.06,15299.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8105.08,,,8105.08,7289.32951,22849.6864,case rate,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,34142.65,23899.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11549.85,,,11549.85,7771.48,33715.2432,case rate,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,18774.77,13142.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6109.56,,,6109.56,6109.56,17431.0928,case rate,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,12926.06,9048.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4383.92,,,4383.92,4310.84101,12464.3864,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,33617.1,23531.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13629.3,,,13629.3,7771.48,38305.0392,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,18826.25,13178.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6740.49,,,6740.49,6278.554375,19579.0768,case rate,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,9263.58,6484.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4795.62,,,4795.62,3089.40393,14237.4864,case rate,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,36248.92,25374.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12074.42,,,12074.42,7771.48,34134.708,case rate,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,33226.4,23258.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7791.07,,,7791.07,7771.48,26581.12,case rate,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,28308.58,19816.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5905.53,,,5905.53,5905.53,22646.864,case rate,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,114168.82,79918.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,44122.13,,,44122.13,7771.48,91335.056,case rate,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,93512.08,65458.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,34664.75,,,34664.75,7771.48,74809.664,case rate,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With McC,456,MS-DRG,,,,,,,inpatient,,,202351.8,141646.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,62210.61,,,62210.61,7771.48,171607.7104,case rate,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,114206.41,79944.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28454.62,,,28454.62,7771.48,91365.128,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,70294.35,49206.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,38820.76,,,38820.76,7771.48,109439.7848,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,25826.71,18078.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21521.67,,,21521.67,7771.48,59750.4304,case rate,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,10589.98,7412.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13339.17,,,13339.17,3531.75833,35176.2776,case rate,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,134518.68,94163.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,38673.16,,,38673.16,7771.48,107614.944,case rate,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,95919.47,67143.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25875.2,,,25875.2,7771.48,76735.576,case rate,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,68797.87,48158.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20288.03,,,20288.03,7771.48,55038.296,case rate,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,54280.26,37996.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22316.84,,,22316.84,7771.48,66232.884,case rate,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,53419.21,37393.447,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13746.52,,,13746.52,7771.48,42735.368,case rate,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,77778.52,54444.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22091.09,,,22091.09,7771.48,62222.816,case rate,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,54869.65,38408.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18379.34,,,18379.34,7771.48,47968.9408,case rate,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,71787.88,50251.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,29468.3,,,29468.3,7771.48,90871.8816,case rate,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,33747.79,23623.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15871.55,,,15871.55,7771.48,43711.4744,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,89768.8,62838.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,24288.48,,,24288.48,7771.48,71815.04,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,65676.03,45973.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17053.09,,,17053.09,7771.48,52540.824,case rate,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,26493.14,18545.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13090.99,,,13090.99,7771.48,35982.7848,case rate,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,50028.86,35020.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21883.44,,,21883.44,7771.48,59596.424,case rate,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,54052.44,37836.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15161.76,,,15161.76,7771.48,43241.952,case rate,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,42724.18,29906.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11915.24,,,11915.24,7771.48,34179.344,case rate,
Knee Procedures With Principal Diagnosis Of Infection With McC,485,MS-DRG,,,,,,,inpatient,,,78688.59,55082.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,24655.31,,,24655.31,7771.48,65323.0304,case rate,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,38633.42,27043.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15544.51,,,15544.51,7771.48,42973.8648,case rate,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,68635.57,48044.899,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14287,,,14287,7771.48,54908.456,case rate,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,35436.81,24805.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9392.98,,,9392.98,7771.48,28349.448,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,77413.36,54189.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25093.78,,,25093.78,7771.48,71957.464,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,79988.8,55992.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16823.73,,,16823.73,7771.48,63991.04,case rate,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,52007.74,36405.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13399.22,,,13399.22,7771.48,41606.192,case rate,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC,495,MS-DRG,,,,,,,inpatient,,,55215.82,38651.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26294.85,,,26294.85,7771.48,71335.3592,case rate,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC,499,MS-DRG,,,,,,,inpatient,,,24343.66,17040.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8673.06,,,8673.06,7771.48,23522.4512,case rate,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,43692.12,30584.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22819.7,,,22819.7,7771.48,64206.484,case rate,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,30673.94,21471.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12625.76,,,12625.76,7771.48,36169.2136,case rate,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,37180.29,26026.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12834.86,,,12834.86,7771.48,35575.4784,case rate,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,63266.34,44286.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14632.13,,,14632.13,7771.48,50613.072,case rate,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,39749.27,27824.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14242.87,,,14242.87,7771.48,39745.8096,case rate,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,26213.06,18349.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11279.97,,,11279.97,7771.48,30507.452,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,64680.35,45276.245,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22697.42,,,22697.42,7771.48,62660.3408,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,33187.16,23231.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14189.32,,,14189.32,7771.48,40763.0624,case rate,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,28664.41,20065.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10105.67,,,10105.67,7771.48,30246.0464,case rate,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,52006.98,36404.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25933.81,,,25933.81,7771.48,72622.1232,case rate,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,60945.78,42662.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14164.72,,,14164.72,7771.48,48756.624,case rate,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,27733.63,19413.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10255.44,,,10255.44,7771.48,29040.3384,case rate,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,64155.47,44908.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22164.89,,,22164.89,7771.48,59061.4544,case rate,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59467.45,41627.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15838.99,,,15838.99,7771.48,47573.96,case rate,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,24348.24,17043.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8927.02,,,8927.02,7771.48,26949.0936,case rate,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,14748.61,10324.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5582.83,,,5582.83,4918.661435,16432.0776,case rate,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,34525.72,24168.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14045.34,,,14045.34,7771.48,40987.9928,case rate,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,27528.18,19269.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9372,,,9372,7771.48,26229.7216,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,28046.03,19632.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13062.05,,,13062.05,7771.48,37790.3336,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,29133.49,20393.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7548.68,,,7548.68,7548.68,23306.792,case rate,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,17251.52,12076.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5616.11,,,5616.11,5616.11,15313.5048,case rate,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,10607.77,7425.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18084.86,,,18084.86,3537.691295,51201.0488,case rate,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,22929.4,16050.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8730.22,,,8730.22,7646.9549,23459.6328,case rate,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,15898.64,11129.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6027.08,,,6027.08,5302.19644,15120.9968,case rate,
Septic Arthritis Without Cc/McC,550,MS-DRG,,,,,,,inpatient,,,13751.03,9625.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6386.68,,,6386.68,4585.968505,17469.5944,case rate,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,34050.51,23835.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11743.76,,,11743.76,7771.48,34576.4632,case rate,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,21070.26,14749.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6815.74,,,6815.74,6815.74,19530.4432,case rate,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,37105.01,25973.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9176.65,,,9176.65,7771.48,29684.008,case rate,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,33214.93,23250.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5718.85,,,5718.85,5718.85,26571.944,case rate,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC,555,MS-DRG,,,,,,,inpatient,,,16910.44,11837.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9860.39,,,9860.39,5639.63174,27285.476,case rate,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,38978.42,27284.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5833.89,,,5833.89,5833.89,31182.736,case rate,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,25775.81,18043.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10085.41,,,10085.41,7771.48,31403.1208,case rate,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,17322.32,12125.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6210.14,,,6210.14,5776.99372,17504.0432,case rate,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,46066.43,32246.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13514.98,,,13514.98,7771.48,37612.0104,case rate,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,43659.99,30561.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7788.17,,,7788.17,7771.48,34927.992,case rate,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,35419.71,24793.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5723.92,,,5723.92,5723.92,28335.768,case rate,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,23360.4,16352.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10187.43,,,10187.43,7771.48,29660.4168,case rate,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,23376.03,16363.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6300.58,,,6300.58,6300.58,18700.824,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,24152.97,16907.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10952.93,,,10952.93,7771.48,31798.2688,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,26103.05,18272.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7280.97,,,7280.97,7280.97,20882.44,case rate,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,12203.73,8542.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5437.4,,,5437.4,4069.943955,15157.472,case rate,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,58121.61,40685.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20521.74,,,20521.74,7771.48,61002.7456,case rate,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,22908.56,16035.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11813.94,,,11813.94,7640.00476,33938.1472,case rate,
Skin Debridement Without Cc/McC,572,MS-DRG,,,,,,,inpatient,,,34042.21,23829.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7977.74,,,7977.74,7771.48,27233.768,case rate,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,40320.12,28224.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,40064.53,,,40064.53,7771.48,124781.6592,case rate,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,31675.49,22172.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23489.69,,,23489.69,7771.48,70208.6808,case rate,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC,575,MS-DRG,,,,,,,inpatient,,,33248.67,23274.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12745.14,,,12745.14,7771.48,40457.076,case rate,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,inpatient,,,22694.73,15886.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18431.43,,,18431.43,7568.692455,53954.9264,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,47774,33441.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21183.77,,,21183.77,7771.48,66042.4024,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,21385.31,14969.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11599.05,,,11599.05,7132.000885,35926.0456,case rate,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,107178.51,75024.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9115.87,,,9115.87,7771.48,85742.808,case rate,
Breast Biopsy- Local Excision And Other Breast Procedures Without Cc/McC,585,MS-DRG,,,,,,,inpatient,,,37278.64,26095.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12606.22,,,12606.22,7771.48,40224.04,case rate,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,53897.07,37727.949,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12203.93,,,12203.93,7771.48,43117.656,case rate,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,22540.18,15778.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5923.61,,,5923.61,5923.61,18032.144,case rate,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,26958.01,18870.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7157.25,,,7157.25,7157.25,21905.384,case rate,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,36927.76,25849.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11842.16,,,11842.16,7771.48,35593.716,case rate,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,9105.56,6373.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8039.97,,,8039.97,3036.70426,21862.8296,case rate,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,5148.62,3604.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4975.05,,,4975.05,1717.06477,12148.268,case rate,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,21201.17,14840.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10394.36,,,10394.36,7070.590195,29775.9216,case rate,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,14711.96,10298.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6112.46,,,6112.46,4906.43866,17850.5576,case rate,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,29329.16,20530.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10790.14,,,10790.14,7771.48,30106.2248,case rate,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21984.9,15389.43,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6578.42,,,6578.42,6578.42,18717.8568,case rate,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,26207.89,18345.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10932.67,,,10932.67,7771.48,32627.0664,case rate,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,18364.58,12855.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5973.54,,,5973.54,5973.54,17514.1752,case rate,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,63303.79,44312.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28860.52,,,28860.52,7771.48,78318.3336,case rate,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,33293.26,23305.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14717.51,,,14717.51,7771.48,39154.1008,case rate,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,inpatient,,,47713.27,33399.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12742.25,,,12742.25,7771.48,38170.616,case rate,
O.R. Procedures For Obesity Without Cc/McC,621,MS-DRG,,,,,,,inpatient,,,43994.97,30796.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11550.58,,,11550.58,7771.48,35195.976,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,39685.45,27779.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26140.02,,,26140.02,7771.48,75868.416,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,19840.3,13888.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13551.16,,,13551.16,6616.74005,38785.296,case rate,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,624,MS-DRG,,,,,,,inpatient,,,15962.42,11173.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7917.69,,,7917.69,5323.46707,20326.8184,case rate,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,76735.34,53714.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26757.2,,,26757.2,7771.48,79967.8232,case rate,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,36824.85,25777.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16980.01,,,16980.01,7771.48,45596.0264,case rate,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,27285.79,19100.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9946.49,,,9946.49,7771.48,29510.4632,case rate,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,17323.96,12126.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6362.8,,,6362.8,5777.54066,18586.1408,case rate,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,11395.93,7977.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4408.52,,,4408.52,3800.542655,12697.4224,case rate,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,21542.6,15079.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8883.61,,,8883.61,7184.4571,26912.6184,case rate,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,14225.97,9958.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5448.25,,,5448.25,4744.360995,15836.316,case rate,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,13622.93,9536.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9315.56,,,9315.56,4543.247155,25149.6504,case rate,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,60349.49,42244.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12034.62,,,12034.62,7771.48,48279.592,case rate,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,13236.15,9265.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7367.8,,,7367.8,4414.256025,20942.844,case rate,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13028.88,9120.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5555.33,,,5555.33,4345.13148,15785.656,case rate,
Major Bladder Procedures Without Cc/McC,655,MS-DRG,,,,,,,inpatient,,,55359.22,38751.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15050.33,,,15050.33,7771.48,44287.376,case rate,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,47307.79,33115.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23744.38,,,23744.38,7771.48,66014.0328,case rate,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,42988.03,30091.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13993.97,,,13993.97,7771.48,37042.592,case rate,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,30491.37,21343.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19280.87,,,19280.87,7771.48,52366.2288,case rate,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,26889.16,18822.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10443.56,,,10443.56,7771.48,27151.7336,case rate,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,19523.55,13666.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7701.35,,,7701.35,6511.103925,20803.0224,case rate,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,57156.94,40009.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21198.25,,,21198.25,7771.48,63211.5216,case rate,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,29787.18,20851.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11539.72,,,11539.72,7771.48,30949.2072,case rate,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,15013.42,10509.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8568.15,,,8568.15,5006.97557,21881.0672,case rate,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,28865.76,20206.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21971.71,,,21971.71,7771.48,69574.4176,case rate,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,28047.28,19633.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12548.34,,,12548.34,7771.48,33378.8608,case rate,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,51984.11,36388.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19934.22,,,19934.22,7771.48,59091.8504,case rate,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,30494.67,21346.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11083.89,,,11083.89,7771.48,31358.54,case rate,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,12447.8,8713.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7065.36,,,7065.36,4151.3413,19364.2784,case rate,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,72572.36,50800.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25056.88,,,25056.88,7771.48,84906.16,case rate,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,49815.27,34870.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17223.12,,,17223.12,7771.48,46775.3912,case rate,
Other Kidney And Urinary Tract Procedures Without Cc/McC,675,MS-DRG,,,,,,,inpatient,,,67065.03,46945.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12676.4,,,12676.4,7771.48,53652.024,case rate,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25198.22,17638.754,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10637.47,,,10637.47,7771.48,30436.528,case rate,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,16815.75,11771.025,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6353.4,,,6353.4,5608.052625,18012.6696,case rate,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,11199.54,7839.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4395.5,,,4395.5,3735.04659,12310.38,case rate,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,17030.3,11921.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13553.33,,,13553.33,5679.60505,38209.7984,case rate,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,10555.37,7388.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7581.24,,,7581.24,3520.215895,21329.8864,case rate,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,21612.22,15128.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8040.69,,,8040.69,7207.67537,23716.9856,case rate,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,14540.91,10178.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5731.88,,,5731.88,4849.393485,16263.8864,case rate,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,27273.94,19091.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9180.26,,,9180.26,7771.48,29794.1592,case rate,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,11406.89,7984.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5276.77,,,5276.77,3804.197815,15834.2896,case rate,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,22314.56,15620.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8221.57,,,8221.57,7441.90576,22851.7128,case rate,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,14767.92,10337.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4990.25,,,4990.25,4925.10132,14016.6088,case rate,
Urethral Stricture,697,MS-DRG,,,,,,,inpatient,,,14675.76,10273.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7213.68,,,7213.68,4894.36596,20300.4752,case rate,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,24798.67,17359.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11625.1,,,11625.1,7771.48,34061.7576,case rate,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,17120.52,11984.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7417.72,,,7417.72,5709.69342,20665.2272,case rate,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,41107.29,28775.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5388.92,,,5388.92,5388.92,32885.832,case rate,
Major Male Pelvic Procedures With Cc/McC,707,MS-DRG,,,,,,,inpatient,,,35017.36,24512.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13896.29,,,13896.29,7771.48,39322.292,case rate,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,31613.04,22129.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10790.86,,,10790.86,7771.48,30039.3536,case rate,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,20964.14,14674.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16727.5,,,16727.5,6991.54069,45533.208,case rate,
Penis Procedures Without Cc/McC,710,MS-DRG,,,,,,,inpatient,,,68393.44,47875.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11575.9,,,11575.9,7771.48,54714.752,case rate,
Testes Procedures With Cc/McC,711,MS-DRG,,,,,,,inpatient,,,36907.35,25835.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15413.55,,,15413.55,7771.48,38716.3984,case rate,
Testes Procedures Without Cc/McC,712,MS-DRG,,,,,,,inpatient,,,18463.04,12924.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7651.42,,,7651.42,6157.42384,21674.3744,case rate,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,14941.94,10459.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10792.31,,,10792.31,4983.13699,29299.7176,case rate,
Transurethral Prostatectomy Without Cc/McC,714,MS-DRG,,,,,,,inpatient,,,10164.77,7115.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6718.06,,,6718.06,3389.950795,19040.0544,case rate,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC,715,MS-DRG,,,,,,,inpatient,,,36701.12,25690.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14607.53,,,14607.53,7771.48,45760.1648,case rate,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,23580.89,16506.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13012.85,,,13012.85,7771.48,37597.8256,case rate,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC,718,MS-DRG,,,,,,,inpatient,,,27747.61,19423.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8944.39,,,8944.39,7771.48,24961.1952,case rate,
Benign Prostatic Hypertrophy With McC,725,MS-DRG,,,,,,,inpatient,,,31783.16,22248.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9275.05,,,9275.05,7771.48,25595.4584,case rate,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,10731.22,7511.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5378.07,,,5378.07,3578.86187,15082.4952,case rate,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,9268.85,6488.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5813.64,,,5813.64,3091.161475,16557.7144,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC,739,MS-DRG,,,,,,,inpatient,,,70791.15,49553.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27651.49,,,27651.49,7771.48,80664.9048,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,inpatient,,,61565.64,43095.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13023.7,,,13023.7,7771.48,49252.512,case rate,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC,741,MS-DRG,,,,,,,inpatient,,,66917.01,46841.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9257.68,,,9257.68,7771.48,53533.608,case rate,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,24878.38,17414.866,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12423.16,,,12423.16,7771.48,37014.2224,case rate,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,27909.66,19536.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8192.63,,,8192.63,7771.48,24288.4304,case rate,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,16030.6,11221.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6786.8,,,6786.8,5346.2051,19354.1464,case rate,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,22664.36,15865.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8158.63,,,8158.63,7558.56406,22495.0664,case rate,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,10151.59,7106.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6996.62,,,6996.62,3385.555265,20655.0952,case rate,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,10881.96,7617.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6675.37,,,6675.37,3629.13366,19970.172,case rate,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14849.95,10394.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8471.19,,,8471.19,4952.458325,13906.65298,case rate,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,6415.51,4490.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6425.75,,,6425.75,2139.572585,21802.0376,case rate,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,10227.7,7159.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5562.57,,,5562.57,3410.93795,14456.3376,case rate,
Abortion Without D&C,779,MS-DRG,,,,,,,inpatient,,,13854.84,9698.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7527.7,,,7527.7,4620.58914,18940.7608,case rate,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,19969.28,13978.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13549.71,,,13549.71,6659.75488,23129.64586,case rate,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,17660.24,12362.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7922.03,,,7922.03,5889.69004,14128.192,case rate,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,16297.53,11408.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6622.55,,,6622.55,5435.226255,13038.024,case rate,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,19789.47,13852.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11512.23,,,11512.23,6599.788245,20332.32622,case rate,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,17268.46,12087.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7689.05,,,7689.05,5759.03141,13814.768,case rate,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,16414.17,11489.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6418.51,,,6418.51,5474.125695,13131.336,case rate,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,4752.37,3326.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12434.02,,,12434.02,1584.915395,22641.16608,case rate,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,54759.69,38331.783,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,41003.68,,,41003.68,2909,73865.99995,case rate,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39693.75,27785.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28003.85,,,28003.85,2909,50556.23959,case rate,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,7967.7,5577.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16896.81,,,16896.81,2657.22795,30643.57784,case rate,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,10068.5,7047.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28765.74,,,28765.74,2909,51923.98297,case rate,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5320.51,3724.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10181.64,,,10181.64,1774.390085,18604.71546,case rate,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4248.78,2974.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,1378.34,,,1378.34,1378.34,7947.23,case rate,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,inpatient,,,55562.6,38893.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21354.53,,,21354.53,7771.48,59041.1904,case rate,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,14129.33,9890.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7429.3,,,7429.3,4712.131555,12691.01849,case rate,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13166.38,9216.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5310.05,,,5310.05,4390.98773,10533.104,case rate,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,12520.32,8764.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4638.61,,,4638.61,4175.52672,10016.256,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,50163.84,35114.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15757.96,,,15757.96,7771.48,46412.6656,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,18648.29,13053.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8839.48,,,8839.48,6219.204715,25096.964,case rate,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,10877.8,7614.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6951.04,,,6951.04,3627.7463,19285.2488,case rate,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,32327.52,22629.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9967.47,,,9967.47,7771.48,28507.3952,case rate,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,22300.24,15610.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6364.97,,,6364.97,6364.97,18701.6456,case rate,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,33797.91,23658.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11176.51,,,11176.51,7771.48,31366.6456,case rate,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,19042.28,13329.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13679.95,,,13679.95,6350.60038,42357.8392,case rate,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,19035.73,13325.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7181.12,,,7181.12,6348.415955,20590.2504,case rate,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,34218.62,23953.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16654.42,,,16654.42,7771.48,51371.2664,case rate,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,53653,37557.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15592.99,,,15592.99,7771.48,45233.3008,case rate,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,70337.4,49236.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,32538.27,,,32538.27,7771.48,94819.3088,case rate,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,inpatient,,,93776.03,65643.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17095.06,,,17095.06,7771.48,75020.824,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,73575.27,51502.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,36443.21,,,36443.21,7771.48,96764.6528,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,inpatient,,,54189.56,37932.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18071.11,,,18071.11,7771.48,47816.9608,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,19580.15,13706.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23194.49,,,23194.49,6529.980025,62486.0704,case rate,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC,830,MS-DRG,,,,,,,inpatient,,,39587.15,27711.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10683.05,,,10683.05,7771.48,31669.72,case rate,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,19450.76,13615.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8111.6,,,8111.6,6486.82846,23321.8376,case rate,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,17150.01,12005.007,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5642.16,,,5642.16,5642.16,15143.2872,case rate,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,11361.65,7953.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,3878.17,,,3878.17,3789.110275,10533.2272,case rate,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,9828.38,6879.866,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,43774.83,,,43774.83,3277.76473,111997.1016,case rate,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,18619.01,13033.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15293.44,,,15293.44,6209.439835,43279.8512,case rate,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,24808.35,17365.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23266.84,,,23266.84,7771.48,64630.0016,case rate,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,16962.7,11873.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11727.12,,,11727.12,5657.06045,31771.9256,case rate,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,19222.18,13455.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13768.22,,,13768.22,6410.59703,38361.7784,case rate,
Radiotherapy,849,MS-DRG,,,,,,,inpatient,,,58144.26,40700.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17998.03,,,17998.03,7771.48,54123.1176,case rate,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,85769.92,60038.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,35776.11,,,35776.11,7771.48,101350.396,case rate,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,33994.9,23796.43,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15153.8,,,15153.8,7771.48,40491.5248,case rate,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65980.01,46186.007,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,32889.91,,,32889.91,7771.48,91416.9832,case rate,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,32658.71,22861.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14721.85,,,14721.85,7771.48,44153.2296,case rate,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,20565.93,14396.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13593.85,,,13593.85,6858.737655,37257.3904,case rate,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,17400.21,12180.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7071.87,,,7071.87,5802.970035,20261.9736,case rate,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,17612.23,12328.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6330.97,,,6330.97,5873.678705,18195.0456,case rate,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,43267.27,30287.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10700.42,,,10700.42,7771.48,34613.816,case rate,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,18403.74,12882.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6057.47,,,6057.47,6057.47,17927.5608,case rate,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,61414.22,42989.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16131.3,,,16131.3,7771.48,49131.376,case rate,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,15482.04,10837.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7657.94,,,7657.94,5163.26034,21277.2,case rate,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,13610,9527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5252.89,,,5252.89,4538.935,14579.948,case rate,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,148503.39,103952.373,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,46485.93,,,46485.93,7771.48,140966.516,case rate,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,33194.92,23236.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13517.16,,,13517.16,7771.48,39764.0472,case rate,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,18792.68,13154.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7391.67,,,7391.67,6267.35878,20892.184,case rate,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,12279.31,8595.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6248.48,,,6248.48,4095.149885,19425.0704,case rate,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,25117.86,17582.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10446.46,,,10446.46,7771.48,33842.9064,case rate,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,22405.38,15683.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8950.9,,,8950.9,7472.19423,28562.108,case rate,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,13917.07,9741.949,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,3961.38,,,3961.38,3961.38,12646.7624,case rate,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,48007.28,33605.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12857.29,,,12857.29,7771.48,38405.824,case rate,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,20565.28,14395.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5972.81,,,5972.81,5972.81,17876.9008,case rate,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,61408.52,42985.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28631.16,,,28631.16,7771.48,80721.644,case rate,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,26863.69,18804.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14763.09,,,14763.09,7771.48,40872.488,case rate,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,27835,19484.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9945.77,,,9945.77,7771.48,25698.8048,case rate,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,30162.14,21113.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11839.99,,,11839.99,7771.48,32791.2048,case rate,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42212,29548.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12282.8,,,12282.8,7771.48,35214.7792,case rate,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,17347.78,12143.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4755.82,,,4755.82,4755.82,13878.224,case rate,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,43962.28,30773.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10690.29,,,10690.29,7771.48,35169.824,case rate,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,17818.34,12472.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5723.92,,,5723.92,5723.92,17921.4816,case rate,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,31482.85,22037.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13272.6,,,13272.6,7771.48,36949.3776,case rate,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,15673.65,10971.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7432.92,,,7432.92,5227.162275,20584.1712,case rate,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,7247.46,5073.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5002.55,,,5002.55,2417.02791,13933.5264,case rate,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,28001.68,19601.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6731.81,,,6731.81,6731.81,22401.344,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC,939,MS-DRG,,,,,,,inpatient,,,23950.54,16765.378,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,24500.48,,,24500.48,7771.48,64313.8832,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,49540.17,34678.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16045.2,,,16045.2,7771.48,42783.3832,case rate,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC,941,MS-DRG,,,,,,,inpatient,,,17064.75,11945.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13925.96,,,13925.96,5691.094125,39599.9088,case rate,
Rehabilitation With Cc/McC,945,MS-DRG,,,,,,,inpatient,,,45131.85,31592.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10742.38,,,10742.38,7771.48,36105.48,case rate,
Rehabilitation Without Cc/McC,946,MS-DRG,,,,,,,inpatient,,,44615.43,31230.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8155.73,,,8155.73,7771.48,35692.344,case rate,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,22069.35,15448.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8610.84,,,8610.84,7360.128225,26061.5304,case rate,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,17906.41,12534.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5684.12,,,5684.12,5684.12,16099.748,case rate,
Aftercare With Cc/McC,949,MS-DRG,,,,,,,inpatient,,,33492.73,23444.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8010.3,,,8010.3,7771.48,26794.184,case rate,
Aftercare Without Cc/McC,950,MS-DRG,,,,,,,inpatient,,,9898.64,6929.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5346.23,,,5346.23,3301.19644,11876.7304,case rate,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,4337.06,3035.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4038.79,,,4038.79,1446.40951,11487.6616,case rate,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,61892.75,43324.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27847.57,,,27847.57,7771.48,77453.0608,case rate,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,12905.91,9034.137,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10769.15,,,10769.15,4304.120985,30400.0528,case rate,
Other Multiple Significant Trauma Without Cc/McC,965,MS-DRG,,,,,,,inpatient,,,19234.18,13463.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6605.19,,,6605.19,6414.59903,18490.9,case rate,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,37958.81,26571.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19432.09,,,19432.09,7771.48,60508.304,case rate,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,12545.67,8781.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9556.5,,,9556.5,4183.980945,29216.6352,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,108861.48,76203.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,33339.23,,,33339.23,7771.48,96341.1352,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,62893.24,44025.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18386.57,,,18386.57,7771.48,50314.592,case rate,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,59507.83,41655.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11973.12,,,11973.12,7771.48,47606.264,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51559.92,36091.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23602.57,,,23602.57,7771.48,70984.792,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,16279.53,11395.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12160.52,,,12160.52,5429.223255,34773.024,case rate,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,989,MS-DRG,,,,,,,inpatient,,,64497.43,45148.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8073.97,,,8073.97,7771.48,51597.944,case rate,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.4373,17.7355,1592,percent of total billed charges,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,547.4092,399.86,2141,percent of total billed charges,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,66.7446,57.921,1592,percent of total billed charges,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,225.3277,195.5395,1592,percent of total billed charges,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,179.0204,155.354,2141,percent of total billed charges,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,481.182,291.227805,2141,percent of total billed charges,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.631,29.185,1592,percent of total billed charges,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,238.5214,206.989,1592,percent of total billed charges,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,238.5214,206.989,1592,percent of total billed charges,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1251.5906,399.86,3715.584,percent of total billed charges,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.9692,205.642,1592,percent of total billed charges,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.9692,205.642,1592,percent of total billed charges,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2235.168,399.86,6635.52,percent of total billed charges,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,303.7138,263.563,1592,percent of total billed charges,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.7111,11.8985,1592,percent of total billed charges,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,526.7132,399.86,2998,percent of total billed charges,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,517.6587,399.86,2998,percent of total billed charges,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,469.5405,399.86,2998,percent of total billed charges,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,182.6422,158.497,3914,percent of total billed charges,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,546.6331,399.86,2141,percent of total billed charges,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,568.3639,399.86,2141,percent of total billed charges,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,263.3566,228.541,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,275.5155,239.0925,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,731.8623,399.86,2477.315575,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,311.2161,270.0735,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,311.2161,270.0735,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,494.117,399.86,1592,percent of total billed charges,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.7689,62.19,1592,percent of total billed charges,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.7689,66.75974,1592,percent of total billed charges,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.8444,47.594,1592,percent of total billed charges,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.4997,96.7595,1592,percent of total billed charges,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.9593,31.2055,1592,percent of total billed charges,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.1333,35.6955,1592,percent of total billed charges,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,495.1518,399.86,1592,percent of total billed charges,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,568.3639,399.86,2141,percent of total billed charges,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.1583,113.876282,1592,percent of total billed charges,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,356.2299,156.65,1592,percent of total billed charges,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,130.6435,113.3725,1592,percent of total billed charges,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,130.6435,113.3725,1592,percent of total billed charges,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.1215,99.9025,1592,percent of total billed charges,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,132.7131,115.1685,1592,percent of total billed charges,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,167.6376,145.476,1592,percent of total billed charges,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,109.9475,95.4125,1592,percent of total billed charges,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.1123,73.8605,1592,percent of total billed charges,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,103.48,89.8,1592,percent of total billed charges,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,123.9173,107.5355,1592,percent of total billed charges,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,163.7571,142.1085,1592,percent of total billed charges,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,201.5273,174.8855,1592,percent of total billed charges,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,143.5785,124.5975,1592,percent of total billed charges,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.8976,100.576,1592,percent of total billed charges,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,356.2299,309.1365,1592,percent of total billed charges,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,209.2883,181.6205,1592,percent of total billed charges,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.5017,200.0295,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,130.6435,113.3725,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.2095,153.7825,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.2095,153.7825,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,167.8963,145.7005,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.1848,399.86,3459.072,percent of total billed charges,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,164.0158,142.333,1592,percent of total billed charges,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,163.7571,142.1085,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,161.1701,139.8635,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,162.2049,140.7615,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,273.1872,237.072,2141,percent of total billed charges,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1355.0706,399.86,4022.784,percent of total billed charges,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.5017,200.0295,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,154.1852,133.802,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,171.5181,148.8435,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,168.6724,146.374,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,193.7663,168.1505,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.0953,318.5655,1592,percent of total billed charges,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,292.8484,254.134,1592,percent of total billed charges,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,473.6797,399.86,1592,percent of total billed charges,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,281.983,244.705,1592,percent of total billed charges,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.675,56.125,1592,percent of total billed charges,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,455.5707,395.3445,1592,percent of total billed charges,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.1445,165.0075,1592,percent of total billed charges,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,78.9035,68.4725,1592,percent of total billed charges,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.2115,257.0525,1592,percent of total billed charges,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.0401,162.3135,1592,percent of total billed charges,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.5286,129.761,1592,percent of total billed charges,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,455.5707,395.3445,1592,percent of total billed charges,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,192.2141,166.8035,1592,percent of total billed charges,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,119.5194,103.719,1592,percent of total billed charges,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.1848,399.86,3459.072,percent of total billed charges,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,473.6797,108.7,1592,percent of total billed charges,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,886.0475,399.86,4341.777195,percent of total billed charges,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1955.2546,399.86,5804.544,percent of total billed charges,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2466.9632,399.86,7323.648,percent of total billed charges,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1508.4797,399.86,4478.208,percent of total billed charges,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1955.2546,399.86,5804.544,percent of total billed charges,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1508.4797,399.86,5481.863562,percent of total billed charges,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2466.9632,399.86,7323.648,percent of total billed charges,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1955.2546,399.86,5804.544,percent of total billed charges,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.6691,88.2285,1592,percent of total billed charges,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,210.0644,182.294,1592,percent of total billed charges,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,210.0644,182.294,1592,percent of total billed charges,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,218.6015,189.7025,1592,percent of total billed charges,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,173.329,150.415,2998,percent of total billed charges,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,456.0881,395.7935,1592,percent of total billed charges,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.4919,367.5065,2141,percent of total billed charges,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,13.47,1592,other,Non-Reimbursable Procedures
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1116.8079,399.86,3315.456,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3070.464,other,Non-Reimbursable Procedures
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,846.2077,399.86,2998,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1794.048,other,Non-Reimbursable Procedures
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1324.544,399.86,3932.16,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1714.176,other,Non-Reimbursable Procedures
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,108.7,2998,percent of total billed charges,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,197.56,1592,other,Non-Reimbursable Procedures
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,547.4092,108.7,2141,percent of total billed charges,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.858,1592,other,Non-Reimbursable Procedures
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,303.9725,108.7,2141,percent of total billed charges,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,61.513,1592,other,Non-Reimbursable Procedures
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,547.4092,108.7,2141,percent of total billed charges,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3633.4415,399.86,14403.82399,percent of total billed charges,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,995.2189,399.86,2954.496,percent of total billed charges,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.8966,399.86,4007.424,percent of total billed charges,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1498.6491,399.86,4449.024,percent of total billed charges,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,212.9101,184.7635,1592,percent of total billed charges,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,233.6061,202.7235,1592,percent of total billed charges,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.2246,147.721,1592,percent of total billed charges,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,184.7118,160.293,1592,percent of total billed charges,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,184.7118,160.293,1592,percent of total billed charges,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,242.6606,210.581,1592,percent of total billed charges,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,194.8011,169.0485,1592,percent of total billed charges,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,194.8011,169.0485,1592,percent of total billed charges,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,477.0428,399.86,2141,percent of total billed charges,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.2246,147.721,1592,percent of total billed charges,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.2246,147.721,1592,percent of total billed charges,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,202.8208,176.008,1592,percent of total billed charges,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4261.5651,399.86,20110.10933,percent of total billed charges,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1240.7252,399.86,3683.328,percent of total billed charges,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,380.5275,1592,other,Non-Reimbursable Procedures
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,647.2674,399.86,2477.315575,percent of total billed charges,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.1445,165.0075,1592,percent of total billed charges,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,932.3548,399.86,2998,percent of total billed charges,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.8966,399.86,4341.777195,percent of total billed charges,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,864.5754,399.86,2998,percent of total billed charges,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.8966,399.86,4007.424,percent of total billed charges,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,274.788,1592,other,Non-Reimbursable Procedures
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1289.1021,399.86,3826.944,percent of total billed charges,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5593.3527,399.86,16604.928,percent of total billed charges,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.8966,399.86,4007.424,percent of total billed charges,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,663.0481,399.86,2455.793921,percent of total billed charges,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,663.0481,399.86,2998,percent of total billed charges,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1289.1021,399.86,3826.944,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1289.1021,399.86,3826.944,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1289.1021,399.86,3826.944,percent of total billed charges,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2841.6,percent of total billed charges,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2841.6,percent of total billed charges,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,905.1913,399.86,2998,percent of total billed charges,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,233.3474,202.499,1592,percent of total billed charges,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,736.7776,399.86,2455.793921,percent of total billed charges,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,173.5877,150.6395,1592,percent of total billed charges,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,529.0415,399.86,2998,percent of total billed charges,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,184.9705,160.5175,1592,percent of total billed charges,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1982.4181,399.86,5885.184,percent of total billed charges,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,324.627,1592,other,Non-Reimbursable Procedures
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,187.233,1592,other,Non-Reimbursable Procedures
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,947.6181,292.65,2813.184,percent of total billed charges,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,171.7768,149.068,1592,percent of total billed charges,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,231.0191,200.4785,1592,percent of total billed charges,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,127.0217,110.2295,1592,percent of total billed charges,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,132.1957,114.7195,1592,percent of total billed charges,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,117.1911,101.6985,1592,percent of total billed charges,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.5798,79.473,1592,percent of total billed charges,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.5798,79.473,1592,percent of total billed charges,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.1727,49.6145,1592,percent of total billed charges,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.3966,48.941,1592,percent of total billed charges,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.7735,90.9225,1592,percent of total billed charges,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.5614,27.389,1592,percent of total billed charges,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.5614,27.389,1592,percent of total billed charges,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.8313,156.9255,1592,percent of total billed charges,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,143.3198,124.373,1592,percent of total billed charges,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.5798,79.473,1592,percent of total billed charges,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.7689,77.9015,1592,percent of total billed charges,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.7689,77.9015,1592,percent of total billed charges,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.7643,64.8805,1592,percent of total billed charges,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.7643,64.8805,1592,percent of total billed charges,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,125.7282,109.107,1592,percent of total billed charges,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.937,114.495,1592,percent of total billed charges,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,140.7328,122.128,1592,percent of total billed charges,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,140.7328,122.128,1592,percent of total billed charges,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,140.7328,122.128,1592,percent of total billed charges,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.1005,138.0675,1592,percent of total billed charges,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,95.9777,83.2895,1592,percent of total billed charges,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,815.1637,399.86,2998,percent of total billed charges,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,814.905,399.86,2998,percent of total billed charges,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1017.9845,399.86,3022.08,percent of total billed charges,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,846.2077,399.86,2998,percent of total billed charges,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.4678,399.86,3528.192,percent of total billed charges,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2164.5429,399.86,6425.856,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,504.7237,399.86,2447.133941,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,504.7237,399.86,2447.133941,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,504.7237,399.86,2447.133941,percent of total billed charges,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,504.7237,399.86,2447.133941,percent of total billed charges,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,585.9555,399.86,2141,percent of total billed charges,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.0226,399.86,3224.064,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,484.8038,399.86,2141,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.2332,367.282,2141,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.2332,367.282,2141,percent of total billed charges,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,749.1952,399.86,2998,percent of total billed charges,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,486.8734,399.86,2447.133941,percent of total billed charges,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,585.9555,399.86,1739.52,percent of total billed charges,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.6127,319.0145,2141,percent of total billed charges,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.6127,319.0145,2141,percent of total billed charges,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1432.4219,399.86,4252.416,percent of total billed charges,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1432.4219,399.86,4252.416,percent of total billed charges,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9511.6229,399.86,28237.056,percent of total billed charges,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5550.6672,399.86,16478.208,percent of total billed charges,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5550.6672,399.86,16478.208,percent of total billed charges,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1042.3023,399.86,4870.452937,percent of total billed charges,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5550.6672,399.86,16478.208,percent of total billed charges,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12670.8673,399.86,37615.872,percent of total billed charges,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.1848,399.86,3459.072,percent of total billed charges,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,702.6292,399.86,2998,percent of total billed charges,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6364,other,Non-Reimbursable Procedures
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,942.7028,399.86,4870.452937,percent of total billed charges,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4601.2382,399.86,13659.648,percent of total billed charges,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5083.9724,399.86,16316.30039,percent of total billed charges,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5841.9634,399.86,29773.2518,percent of total billed charges,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17461.2152,399.86,51836.928,percent of total billed charges,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16814.9826,399.86,50269.54813,percent of total billed charges,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5550.6672,399.86,16478.208,percent of total billed charges,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2335.5436,399.86,6933.504,percent of total billed charges,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22347.5408,399.86,66342.912,percent of total billed charges,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16299.6522,399.86,48388.608,percent of total billed charges,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17010.0424,399.86,50497.536,percent of total billed charges,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17010.0424,399.86,50497.536,percent of total billed charges,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7173.2336,399.86,21295.104,percent of total billed charges,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7173.2336,399.86,21295.104,percent of total billed charges,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,22573.824,percent of total billed charges,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,22573.824,percent of total billed charges,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7173.2336,399.86,23502.2528,percent of total billed charges,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,24913.5068,percent of total billed charges,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,24913.5068,percent of total billed charges,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1798.2237,399.86,5338.368,percent of total billed charges,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1544.439,399.86,4584.96,percent of total billed charges,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.454,399.86,3746.392,percent of total billed charges,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,426.5963,370.2005,2998,percent of total billed charges,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.234,399.86,3237.832,percent of total billed charges,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1084.9878,399.86,3220.992,percent of total billed charges,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,465.66,399.86,2998,percent of total billed charges,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,650.1131,399.86,6913,percent of total billed charges,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.9593,31.2055,6913,percent of total billed charges,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.9983,399.86,3155.712,percent of total billed charges,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.4356,399.86,3549.7488,percent of total billed charges,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.4356,399.86,3549.7488,percent of total billed charges,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.9983,399.86,3155.712,percent of total billed charges,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.4356,293.5896,3216.384,percent of total billed charges,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,457.899,397.365,2141,percent of total billed charges,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,457.899,397.365,2141,percent of total billed charges,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,39.3224,34.124,2998,percent of total billed charges,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.5706,53.431,2998,percent of total billed charges,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.2029,37.4915,2998,percent of total billed charges,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.1819,75.6565,2998,percent of total billed charges,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.6389,100.3515,2998,percent of total billed charges,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.3966,48.941,2998,percent of total billed charges,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,77.0035,1592,other,Non-Reimbursable Procedures
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,200.4925,173.9875,2141,percent of total billed charges,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,57.921,1592,other,Non-Reimbursable Procedures
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,121.4545,1592,other,Non-Reimbursable Procedures
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,173.5385,1592,other,Non-Reimbursable Procedures
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,204.0705,1592,other,Non-Reimbursable Procedures
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6398.208,other,Non-Reimbursable Procedures
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,161.8645,1592,other,Non-Reimbursable Procedures
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,373.119,1592,other,Non-Reimbursable Procedures
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,140.986,1592,other,Non-Reimbursable Procedures
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,76.33,1592,other,Non-Reimbursable Procedures
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2003.712,other,Non-Reimbursable Procedures
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,161.8645,1592,other,Non-Reimbursable Procedures
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.235,1592,other,Non-Reimbursable Procedures
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.516,1592,other,Non-Reimbursable Procedures
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,346.8525,1592,other,Non-Reimbursable Procedures
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.4705,1592,other,Non-Reimbursable Procedures
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2507.0617,399.86,7442.688,percent of total billed charges,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2507.0617,399.86,7442.688,percent of total billed charges,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2364.7767,399.86,8396.844904,percent of total billed charges,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4099.6189,399.86,12170.496,percent of total billed charges,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2364.7767,399.86,7020.288,percent of total billed charges,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4099.6189,399.86,12170.496,percent of total billed charges,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,115.6175,1592,other,Non-Reimbursable Procedures
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.394,1592,other,Non-Reimbursable Procedures
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.5215,1592,other,Non-Reimbursable Procedures
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,277.482,1592,other,Non-Reimbursable Procedures
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,323.729,1592,other,Non-Reimbursable Procedures
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,57.921,1592,other,Non-Reimbursable Procedures
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.541,399.86,7242.24,percent of total billed charges,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.541,399.86,7242.24,percent of total billed charges,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.541,399.86,8396.844904,percent of total billed charges,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.541,399.86,7242.24,percent of total billed charges,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,5.388,416.02,other,Non-Reimbursable Procedures
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,238.7801,207.2135,1592,percent of total billed charges,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.1583,156.65,1592,percent of total billed charges,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.1583,204.0705,1592,percent of total billed charges,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.0821,85.9835,1592,percent of total billed charges,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,6623.08,percent of total billed charges,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1592,other,Non-Reimbursable Procedures
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1592,other,Non-Reimbursable Procedures
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,205.4175,1592,other,Non-Reimbursable Procedures
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,92.494,1592,other,Non-Reimbursable Procedures
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,173.5385,1592,other,Non-Reimbursable Procedures
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,345.8819,300.1565,2081.64,percent of total billed charges,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1272.5453,399.86,3777.792,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,6012.672,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,6012.672,percent of total billed charges,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2025.3623,399.86,6012.672,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2953.728,percent of total billed charges,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,994.9602,399.86,2953.728,percent of total billed charges,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.6127,319.0145,2141,percent of total billed charges,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.6127,319.0145,2141,percent of total billed charges,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2998,percent of total billed charges,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,35.92,1592,other,Non-Reimbursable Procedures
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,28.0625,1592,other,Non-Reimbursable Procedures
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.5122,180.947,1592,percent of total billed charges,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,105.0322,91.147,1592,percent of total billed charges,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,66.6765,1592,other,Non-Reimbursable Procedures
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,69.3705,1592,other,Non-Reimbursable Procedures
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2768.6074,399.86,9071.0152,percent of total billed charges,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,146.9416,127.516,1592,percent of total billed charges,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,146.9416,127.516,1592,percent of total billed charges,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1065.844,399.86,5756,percent of total billed charges,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3372.1545,399.86,18955.84,percent of total billed charges,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,26793.51305,percent of total billed charges,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,184.988,4800.911611,other,Non-Reimbursable Procedures
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,277.482,8164.18419,other,Non-Reimbursable Procedures
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,6788.57,percent of total billed charges,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3629.561,399.86,10775.04,percent of total billed charges,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2490.7636,399.86,7394.304,percent of total billed charges,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2586.4826,399.86,7678.464,percent of total billed charges,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,158.5831,137.6185,1592,percent of total billed charges,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2283.0275,399.86,6777.6,percent of total billed charges,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,837.9293,399.86,4870.452937,percent of total billed charges,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1868.8488,399.86,5548.032,percent of total billed charges,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1868.8488,399.86,5548.032,percent of total billed charges,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,143.0611,124.1485,2998,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4137.6478,399.86,12283.392,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4293.6439,399.86,18955.84,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12148.224,other,Non-Reimbursable Procedures
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12453.888,other,Non-Reimbursable Procedures
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4294.1613,399.86,12748.032,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8813.909,399.86,26793.51305,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8428.1873,399.86,25020.672,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15264.5935,399.86,45315.84,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4138.9413,399.86,16809.6787,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9019.8342,399.86,26793.51305,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8813.909,399.86,26793.51305,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15042.3702,399.86,44656.128,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12327.936,other,Non-Reimbursable Procedures
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,25786.368,other,Non-Reimbursable Procedures
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12327.936,other,Non-Reimbursable Procedures
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12148.224,other,Non-Reimbursable Procedures
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4532,other,Non-Reimbursable Procedures
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4532,other,Non-Reimbursable Procedures
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,26793.51305,percent of total billed charges,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1201.1441,399.86,3565.824,percent of total billed charges,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,98.5647,85.5345,1592,percent of total billed charges,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.4151,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.4151,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.1564,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.1564,399.86,2477.315575,percent of total billed charges,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1203.7311,399.86,4341.777195,percent of total billed charges,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1203.7311,399.86,4341.777195,percent of total billed charges,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.4151,399.86,2998,percent of total billed charges,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.35,112.25,1592,percent of total billed charges,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,139.698,121.23,1592,percent of total billed charges,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,672.1026,399.86,2477.315575,percent of total billed charges,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.4919,367.5065,2141,percent of total billed charges,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,95.188,1592,other,Non-Reimbursable Procedures
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.8871,119.6585,1592,percent of total billed charges,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.2095,153.7825,1592,percent of total billed charges,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.0775,72.9625,1592,percent of total billed charges,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.0775,72.9625,1592,percent of total billed charges,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,129.9855,1592,other,Non-Reimbursable Procedures
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,128.3152,111.352,1592,percent of total billed charges,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,227.3973,197.3355,1592,percent of total billed charges,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,227.3973,197.3355,1592,percent of total billed charges,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,432.8051,375.5885,2998,percent of total billed charges,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.4749,399.86,4005.9,percent of total billed charges,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1662.1475,399.86,4934.4,percent of total billed charges,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,961.3292,399.86,2998,percent of total billed charges,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,218.214,1592,other,Non-Reimbursable Procedures
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3442.5209,399.86,10219.776,percent of total billed charges,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2164.5429,399.86,6425.856,percent of total billed charges,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2164.5429,399.86,6425.856,percent of total billed charges,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3442.5209,399.86,15728.70471,percent of total billed charges,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,450.138,390.63,2998,percent of total billed charges,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2215.5068,399.86,6577.152,percent of total billed charges,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2215.5068,399.86,6577.152,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,239.2975,207.6625,2998,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.9745,367.0575,2998,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.9745,367.0575,2998,percent of total billed charges,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2164.5429,399.86,6425.856,percent of total billed charges,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,742.469,399.86,2998,percent of total billed charges,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,684.7789,399.86,2998,percent of total billed charges,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2060.2868,399.86,6116.352,percent of total billed charges,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1104.9077,399.86,3280.128,percent of total billed charges,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.2295,1592,other,Non-Reimbursable Procedures
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1104.9077,399.86,3280.128,percent of total billed charges,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1104.9077,399.86,3280.128,percent of total billed charges,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,425.3028,369.078,2998,percent of total billed charges,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,425.3028,369.078,2998,percent of total billed charges,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.7204,379.854,2998,percent of total billed charges,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.7204,379.854,2998,percent of total billed charges,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,677.0179,399.86,2998,percent of total billed charges,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,677.0179,399.86,2998,percent of total billed charges,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,550.5136,399.86,2998,percent of total billed charges,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,156.7722,136.047,1592,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.010023,1.160665,416.02,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.337479,1.160665,416.02,percent of total billed charges,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,4179.83,percent of total billed charges,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,391.4131,339.6685,2141,percent of total billed charges,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.8162,162.987,2141,percent of total billed charges,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.8871,119.6585,1592,percent of total billed charges,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,391.4131,334.48,2141,percent of total billed charges,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1423.3674,399.86,4225.536,percent of total billed charges,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3001.6961,399.86,8911.104,percent of total billed charges,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3442.5209,399.86,10219.776,percent of total billed charges,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,83.963,1592,other,Non-Reimbursable Procedures
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,119.6585,1592,other,Non-Reimbursable Procedures
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3001.6961,399.86,8911.104,percent of total billed charges,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3001.6961,399.86,8911.104,percent of total billed charges,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.8313,156.9255,1592,percent of total billed charges,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.8313,156.9255,1592,percent of total billed charges,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,625.7953,179.53,2998,percent of total billed charges,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,625.7953,179.53,2998,percent of total billed charges,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,219.112,1592,other,Non-Reimbursable Procedures
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,227.3973,197.3355,1592,percent of total billed charges,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,100.6343,87.3305,1592,percent of total billed charges,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.1517,87.7795,1592,percent of total billed charges,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.5798,79.473,1592,percent of total billed charges,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,117.9672,102.372,1592,percent of total billed charges,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,122.8825,106.6375,1592,percent of total billed charges,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.8444,47.594,1592,percent of total billed charges,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2091.8482,399.86,6210.048,percent of total billed charges,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1707.1613,399.86,5068.032,percent of total billed charges,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,152.8917,120.28264,1592,percent of total billed charges,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,214.4623,186.1105,1592,percent of total billed charges,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1296.8631,399.86,4777.053449,percent of total billed charges,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1785.03,399.86,5299.2,percent of total billed charges,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,126.763,110.005,416.02,percent of total billed charges,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,792.1394,399.86,4777.053449,percent of total billed charges,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1856.4312,399.86,5511.168,percent of total billed charges,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,391.6718,339.893,2141,percent of total billed charges,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1561.2545,399.86,11413.04,percent of total billed charges,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,487.6495,399.86,2141,percent of total billed charges,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.8871,119.6585,5756,percent of total billed charges,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.4919,367.5065,2141,percent of total billed charges,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,205.4175,2141,percent of total billed charges,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,205.4175,2141,percent of total billed charges,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,205.4175,2141,percent of total billed charges,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,324.9272,281.972,2141,percent of total billed charges,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,324.9272,281.972,2141,percent of total billed charges,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,205.4175,2141,percent of total billed charges,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,294.544,1592,other,Non-Reimbursable Procedures
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1630.8448,399.86,6224.0876,percent of total billed charges,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,281.972,1592,other,Non-Reimbursable Procedures
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.5215,1592,other,Non-Reimbursable Procedures
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,668.9982,399.86,2141,percent of total billed charges,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,212.3927,155.844464,1592,percent of total billed charges,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.5017,200.0295,1592,percent of total billed charges,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.7158,323.2601,1592,percent of total billed charges,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.8799,196.8865,1592,percent of total billed charges,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,357.5234,310.259,2141,percent of total billed charges,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1575.483,399.86,4677.12,percent of total billed charges,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.7158,366.833,2141,percent of total billed charges,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.4275,185.2125,1592,percent of total billed charges,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.635,1592,other,Non-Reimbursable Procedures
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,93.392,1592,other,Non-Reimbursable Procedures
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.1727,49.6145,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.9488,50.288,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.9698,12.123,1592,percent of total billed charges,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,560.0855,399.86,2141,percent of total billed charges,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.7269,154.2315,1592,percent of total billed charges,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.7269,154.2315,1592,percent of total billed charges,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,46.0225,1592,other,Non-Reimbursable Procedures
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,66.75974,1592,other,Non-Reimbursable Procedures
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,70.1077,60.8395,416.02,percent of total billed charges,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,153.9265,71.24,456.96,percent of total billed charges,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,126.5043,76.026473,416.02,percent of total billed charges,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.3408,86.208,416.02,percent of total billed charges,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.3165,66.2275,416.02,percent of total billed charges,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.9232,71.24,416.02,percent of total billed charges,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.1924,56.574,416.02,percent of total billed charges,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.5253,71.24,416.02,percent of total billed charges,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.8536,73.636,416.02,percent of total billed charges,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.8536,71.24,416.02,percent of total billed charges,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.8628,71.24,416.02,percent of total billed charges,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.7794,58.819,416.02,percent of total billed charges,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.0624,76.026473,416.02,percent of total billed charges,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,108.3953,76.026473,416.02,percent of total billed charges,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,185.2292,71.24,549.888,percent of total billed charges,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,276.55,,,276.55,267.439885,1987.584,fee schedule,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.0184,52.084,416.02,percent of total billed charges,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.7794,58.819,416.02,percent of total billed charges,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,120.5565,646.6965,other,Non-Reimbursable Procedures
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,89.81,,,89.81,89.81,821.76,fee schedule,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,124.33,,,124.33,124.33,1023.744,fee schedule,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,153.75,,,153.75,153.75,1240.32,fee schedule,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,182.39,,,182.39,96.160741,575,fee schedule,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,246.33,,,246.33,173.763,667.43,fee schedule,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,276.94,,,276.94,200.53123,1243.392,fee schedule,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,165.13,,,165.13,96.160741,921.6,fee schedule,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,204.36,,,204.36,200.53123,1014.528,fee schedule,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,252.22,,,252.22,200.53123,889.344,fee schedule,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,154.93,,,154.93,96.160741,575,fee schedule,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,194.55,,,194.55,194.55,1138.176,fee schedule,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,241.63,,,241.63,200.53123,1347.84,fee schedule,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,396.2,,,396.2,200.53123,1021.44,fee schedule,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,415.42,,,415.42,200.53123,888.576,fee schedule,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,324.41,,,324.41,237.688956,3902.208,fee schedule,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,365.99,,,365.99,365.99,2081.28,fee schedule,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,439.74,,,439.74,379.854,1299.456,fee schedule,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,380.9,,,380.9,267.439885,1750.272,fee schedule,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,374.62,,,374.62,374.62,1750.272,fee schedule,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,572.73,,,572.73,301.425681,1750.272,fee schedule,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,382.07,,,382.07,267.439885,1675.776,fee schedule,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,404.43,,,404.43,399.86,1896.192,fee schedule,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,577.44,,,577.44,301.425681,1946.112,fee schedule,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,188.66,,,188.66,188.66,1605.12,fee schedule,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,268.7,,,268.7,268.7,4035.84,fee schedule,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,307.14,,,307.14,307.14,2049.024,fee schedule,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.3618,48.043,416.02,percent of total billed charges,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.0184,52.084,416.02,percent of total billed charges,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,63.3815,55.0025,416.02,percent of total billed charges,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.067,76.026473,416.02,percent of total billed charges,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,125.2108,76.026473,416.02,percent of total billed charges,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,145.3894,76.026473,431.616,percent of total billed charges,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,71.24,416.02,percent of total billed charges,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.675,56.125,416.02,percent of total billed charges,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,154.93,,,154.93,96.160741,1065.984,fee schedule,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,195.34,,,195.34,195.34,1247.232,fee schedule,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,242.81,,,242.81,200.53123,1522.176,fee schedule,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.2968,59.268,575,percent of total billed charges,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,305.97,,,305.97,200.53123,1222.656,fee schedule,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,378.94,,,378.94,237.688956,1519.872,fee schedule,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,424.05,,,424.05,399.86,2402.304,fee schedule,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,529.58,,,529.58,347.3015,1288.93,fee schedule,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,612.3429,301.425681,1817.856,percent of total billed charges,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,612.3429,301.425681,1817.856,percent of total billed charges,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,612.3429,301.425681,1817.856,percent of total billed charges,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.9337,56.3495,416.02,percent of total billed charges,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.5752,66.452,416.02,percent of total billed charges,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,77.61,67.35,416.02,percent of total billed charges,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,77.61,67.35,416.02,percent of total billed charges,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.1924,56.574,416.02,percent of total billed charges,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,73.2121,63.5335,416.02,percent of total billed charges,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.1622,68.697,416.02,percent of total billed charges,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,71.24,416.02,percent of total billed charges,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.5995,86.4325,416.02,percent of total billed charges,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.8359,119.991125,581.376,percent of total billed charges,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.8359,76.026473,581.376,percent of total billed charges,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.7945,52.7575,416.02,percent of total billed charges,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,83.5601,72.5135,416.02,percent of total billed charges,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.7374,76.026473,462.336,percent of total billed charges,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.3257,92.2695,416.02,percent of total billed charges,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,156.89,,,156.89,96.160741,1043.712,fee schedule,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,196.52,,,196.52,196.52,1195.008,fee schedule,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,244.38,,,244.38,200.53123,1719.552,fee schedule,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,156.11,,,156.11,96.160741,698.112,fee schedule,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,196.52,,,196.52,196.52,796.416,fee schedule,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,247.91,,,247.91,200.53123,1704.192,fee schedule,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,155.32,,,155.32,96.160741,575,fee schedule,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,195.73,,,195.73,195.73,1095.936,fee schedule,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,244.77,,,244.77,200.53123,1057.536,fee schedule,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,185.92,,,185.92,185.92,1624.32,fee schedule,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,270.27,,,270.27,270.27,2337.024,fee schedule,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,185.92,,,185.92,185.92,1706.496,fee schedule,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,266.73,,,266.73,266.73,2183.424,fee schedule,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,185.92,,,185.92,185.92,2035.968,fee schedule,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,265.17,,,265.17,265.17,2031.36,fee schedule,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,307.53,,,307.53,307.53,2399.232,fee schedule,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,307.93,,,307.93,307.93,2175.744,fee schedule,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,305.58,,,305.58,305.58,2443.008,fee schedule,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,64.4315,416.02,percent of total billed charges,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,328.72,,,328.72,200.53123,974.592,fee schedule,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,106.67,,,106.67,96.160741,1050.624,fee schedule,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,195.33,,,195.33,195.33,1198.848,fee schedule,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,236.92,,,236.92,200.53123,1460.736,fee schedule,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,335.78,,,335.78,237.688956,1721.088,fee schedule,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,372.27,,,372.27,372.27,2188.8,fee schedule,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,447.2,,,447.2,399.547552,2114.304,fee schedule,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,752.2996,399.86,2233.344,percent of total billed charges,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,701.077,399.86,2233.344,percent of total billed charges,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,472.3862,399.86,2233.344,percent of total billed charges,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.6041,76.026473,416.02,percent of total billed charges,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.9232,71.24,416.02,percent of total billed charges,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,331.811,2051.3855,other,Non-Reimbursable Procedures
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2051.3855,other,Non-Reimbursable Procedures
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,395.12,2051.3855,other,Non-Reimbursable Procedures
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2051.3855,other,Non-Reimbursable Procedures
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4977.9345,other,Non-Reimbursable Procedures
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4977.9345,other,Non-Reimbursable Procedures
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.979,38.165,416.02,percent of total billed charges,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.1622,68.697,416.02,percent of total billed charges,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,66.2272,57.472,416.02,percent of total billed charges,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.9593,31.2055,416.02,percent of total billed charges,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,379.405,1297.92,other,Non-Reimbursable Procedures
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,83.5601,71.24,416.02,percent of total billed charges,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.0486,39.961,416.02,percent of total billed charges,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.2377,38.3895,416.02,percent of total billed charges,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.3723,28.9605,416.02,percent of total billed charges,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,298.8095,1022.208,other,Non-Reimbursable Procedures
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,58.2075,50.5125,416.02,percent of total billed charges,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,95.2016,76.026473,416.02,percent of total billed charges,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.153,42.655,416.02,percent of total billed charges,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1322.496,other,Non-Reimbursable Procedures
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.1622,68.697,416.02,percent of total billed charges,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.0532,52.982,416.02,percent of total billed charges,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.3723,28.9605,416.02,percent of total billed charges,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,154.93,,,154.93,96.160741,736.512,fee schedule,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,193.37,,,193.37,193.37,1065.984,fee schedule,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,261.64,,,261.64,200.53123,1506.048,fee schedule,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,271.05,,,271.05,200.53123,1032.96,fee schedule,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,331.08,,,331.08,237.688956,2217.984,fee schedule,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,371.09,,,371.09,371.09,2254.848,fee schedule,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,447.2,,,447.2,399.547552,2414.592,fee schedule,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,204.76,,,204.76,204.76,2333.952,fee schedule,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,340.49,,,340.49,340.49,2414.592,fee schedule,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,415.03,,,415.03,399.547552,2350.08,fee schedule,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.4314,49.839,416.02,percent of total billed charges,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.4314,49.839,416.02,percent of total billed charges,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.5995,86.4325,416.02,percent of total billed charges,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.5995,86.4325,416.02,percent of total billed charges,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.8359,76.026473,581.376,percent of total billed charges,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1241.088,other,Non-Reimbursable Procedures
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.1031,47.8185,416.02,percent of total billed charges,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.1031,47.8185,416.02,percent of total billed charges,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.0184,52.084,416.02,percent of total billed charges,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.262,58.37,416.02,percent of total billed charges,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.9278,71.24,416.02,percent of total billed charges,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,382.548,1308.672,other,Non-Reimbursable Procedures
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,51.4813,44.6755,416.02,percent of total billed charges,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,59.7597,51.8595,416.02,percent of total billed charges,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.4419,30.7565,416.02,percent of total billed charges,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.631,29.185,416.02,percent of total billed charges,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1020.2995,other,Non-Reimbursable Procedures
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.8746,35.471,416.02,percent of total billed charges,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.4268,36.818,416.02,percent of total billed charges,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.5358,52.533,416.02,percent of total billed charges,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.6704,43.104,416.02,percent of total billed charges,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,154.93,,,154.93,96.160741,743.424,fee schedule,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,196.51,,,196.51,196.51,758.016,fee schedule,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,258.89,,,258.89,200.53123,1461.504,fee schedule,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,306.75,,,306.75,200.53123,903.168,fee schedule,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,331.08,,,331.08,237.688956,2178.048,fee schedule,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,372.66,,,372.66,372.66,1840.128,fee schedule,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,450.72,,,450.72,399.547552,2350.08,fee schedule,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,205.15,,,205.15,205.15,2310.144,fee schedule,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,345.98,,,345.98,345.98,2317.824,fee schedule,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,416.6,,,416.6,399.547552,2379.264,fee schedule,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,701.077,399.86,2290.176,percent of total billed charges,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,701.077,399.86,2290.176,percent of total billed charges,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,771.4434,399.86,2290.176,percent of total billed charges,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.0184,52.084,416.02,percent of total billed charges,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.6041,76.026473,416.02,percent of total billed charges,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.067,92.045,416.02,percent of total billed charges,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,104.32,,,104.32,96.160741,1112.832,fee schedule,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,194.55,,,194.55,194.55,1218.048,fee schedule,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,228.68,,,228.68,200.53123,1580.544,fee schedule,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,478.18,,,478.18,329.339098,1982.208,fee schedule,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,321.66,,,321.66,200.53123,1040.64,fee schedule,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,142.38,,,142.38,142.38,1050.624,fee schedule,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,256.93,,,256.93,204.61123,1513.728,fee schedule,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,305.18,,,305.18,204.61123,1629.696,fee schedule,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,291.45,,,291.45,237.688956,1810.176,fee schedule,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,416.99,,,416.99,399.547552,3902.208,fee schedule,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,449.16,,,449.16,399.547552,2072.064,fee schedule,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,632.7802,301.425681,1878.528,percent of total billed charges,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,632.7802,301.425681,1878.528,percent of total billed charges,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,632.7802,301.425681,1878.528,percent of total billed charges,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,253.7847,76.026473,753.408,percent of total billed charges,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.1038,128.66,671.232,percent of total billed charges,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,259.7465,888.576,other,Non-Reimbursable Procedures
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.9692,200.53123,703.488,percent of total billed charges,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,223.7755,194.1925,664.32,percent of total billed charges,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,762.9063,128.66,2264.832,percent of total billed charges,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,305.7834,183.14,907.776,percent of total billed charges,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,277.0677,200.53123,822.528,percent of total billed charges,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,454.7946,200.53123,1350.144,percent of total billed charges,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,1026.048,other,Non-Reimbursable Procedures
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,64.8805,416.02,other,Non-Reimbursable Procedures
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,797.184,other,Non-Reimbursable Procedures
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.08,669.696,other,Non-Reimbursable Procedures
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,260.23,2237.184,other,Non-Reimbursable Procedures
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,141.6595,484.608,other,Non-Reimbursable Procedures
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1890.816,other,Non-Reimbursable Procedures
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,154.9613,134.4755,499.422,percent of total billed charges,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,537.5786,200.53123,1595.904,percent of total billed charges,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,307.5943,237.819698,1020.2995,percent of total billed charges,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2172.672,other,Non-Reimbursable Procedures
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1020.2995,other,Non-Reimbursable Procedures
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,171.069,646.6965,other,Non-Reimbursable Procedures
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,171.069,646.6965,other,Non-Reimbursable Procedures
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,121.679,1393.3385,other,Non-Reimbursable Procedures
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5136.771,other,Non-Reimbursable Procedures
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1301.76,other,Non-Reimbursable Procedures
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,285.115,975.36,other,Non-Reimbursable Procedures
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,234.18,,,234.18,88.902,1706.496,fee schedule,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,234.18,,,234.18,88.902,1706.496,fee schedule,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,336.18,,,336.18,102.5965,2030.592,fee schedule,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,336.18,,,336.18,102.5965,2030.592,fee schedule,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,47.83,,,47.83,9.2045,836,fee schedule,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,47.83,,,47.83,9.2045,836,fee schedule,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31.78,,,31.78,19.0825,575,fee schedule,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31.78,,,31.78,19.0825,575,fee schedule,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,223.19,,,223.19,58.819,669.696,fee schedule,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,223.19,,,223.19,58.819,669.696,fee schedule,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,298.51,,,298.51,58.819,780.288,fee schedule,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,298.51,,,298.51,58.819,780.288,fee schedule,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,320.09,,,320.09,57.921,824.064,fee schedule,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,320.09,,,320.09,57.921,824.064,fee schedule,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,738.8472,399.86,2536.61118,percent of total billed charges,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,330.22,,,330.22,200.53123,1321.728,fee schedule,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2543.2797,399.86,14233.715,percent of total billed charges,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2717.184,other,Non-Reimbursable Procedures
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,92.2695,416.02,other,Non-Reimbursable Procedures
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1991.4726,399.86,8249.769,percent of total billed charges,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4120.349,other,Non-Reimbursable Procedures
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4120.349,other,Non-Reimbursable Procedures
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4120.349,other,Non-Reimbursable Procedures
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3400.704,other,Non-Reimbursable Procedures
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,367.731,1602.0655,other,Non-Reimbursable Procedures
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,1947.648,other,Non-Reimbursable Procedures
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,260.23,8249.769,other,Non-Reimbursable Procedures
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,260.23,3665.664,other,Non-Reimbursable Procedures
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,105.7395,416.02,other,Non-Reimbursable Procedures
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,324.627,1110.528,other,Non-Reimbursable Procedures
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,294.544,1007.616,other,Non-Reimbursable Procedures
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,189.7025,648.96,other,Non-Reimbursable Procedures
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,167.028,571.392,other,Non-Reimbursable Procedures
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,2241.024,other,Non-Reimbursable Procedures
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,2215.68,other,Non-Reimbursable Procedures
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,681.984,other,Non-Reimbursable Procedures
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,681.984,other,Non-Reimbursable Procedures
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,257.9239,195.08,765.696,percent of total billed charges,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.958,71.24,416.02,percent of total billed charges,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1497.6,other,Non-Reimbursable Procedures
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,254.5608,220.908,1393.3385,percent of total billed charges,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,98.8234,85.759,416.02,percent of total billed charges,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.024,836,other,Non-Reimbursable Procedures
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.024,836,other,Non-Reimbursable Procedures
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.024,836,other,Non-Reimbursable Procedures
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,94.739,836,other,Non-Reimbursable Procedures
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,94.739,836,other,Non-Reimbursable Procedures
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,94.739,836,other,Non-Reimbursable Procedures
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,113.35,,,113.35,71.24,712.704,fee schedule,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,412.28,,,412.28,81.08,1703.424,fee schedule,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,189.029,836,percent of total billed charges,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,59.2423,51.4105,575,percent of total billed charges,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,112.0171,97.2085,416.02,percent of total billed charges,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.8628,99.678,416.02,percent of total billed charges,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,107.8779,93.6165,416.02,percent of total billed charges,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.5995,86.4325,416.02,percent of total billed charges,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.3211,71.24,416.02,percent of total billed charges,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,119.2607,103.4945,416.02,percent of total billed charges,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,88.2167,76.5545,416.02,percent of total billed charges,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.5207,58.5945,416.02,percent of total billed charges,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,95.2016,82.616,416.02,percent of total billed charges,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.2515,77.4525,416.02,percent of total billed charges,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,153.9265,119.991125,456.96,percent of total billed charges,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.7643,64.8805,416.02,percent of total billed charges,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.9488,50.288,416.02,percent of total billed charges,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,108.9127,94.5145,416.02,percent of total billed charges,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,184.4531,157.086513,547.584,percent of total billed charges,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.5575,162.7625,646.6965,percent of total billed charges,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.088,53.88,416.02,percent of total billed charges,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,78.3861,68.0235,416.02,percent of total billed charges,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.22,119.991125,460.8,percent of total billed charges,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.8385,79.6975,416.02,percent of total billed charges,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,113.5693,98.5555,416.02,percent of total billed charges,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,80.371,416.02,percent of total billed charges,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.023,65.105,416.02,percent of total billed charges,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.5286,119.991125,443.904,percent of total billed charges,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.7702,32.777,416.02,percent of total billed charges,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,94.4255,81.9425,416.02,percent of total billed charges,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,260.2522,199.512292,772.608,percent of total billed charges,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.3907,81.0445,416.02,percent of total billed charges,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.8884,74.534,416.02,percent of total billed charges,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,118.2259,102.5965,416.02,percent of total billed charges,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,103.7387,90.0245,416.02,percent of total billed charges,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,70.6251,61.2885,416.02,percent of total billed charges,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,103.48,89.8,416.02,percent of total billed charges,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.4511,56.7985,416.02,percent of total billed charges,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.5844,71.24,416.02,percent of total billed charges,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.5844,71.24,416.02,percent of total billed charges,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,176.1747,152.8845,775.5705,percent of total billed charges,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,56.3495,416.02,other,Non-Reimbursable Procedures
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,103.27,416.02,other,Non-Reimbursable Procedures
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,166.37,666.624,other,Non-Reimbursable Procedures
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.473,416.02,other,Non-Reimbursable Procedures
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,135.598,463.872,other,Non-Reimbursable Procedures
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,116.9645,416.02,other,Non-Reimbursable Procedures
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,71.391,416.02,other,Non-Reimbursable Procedures
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,116.291,416.02,other,Non-Reimbursable Procedures
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1383.168,other,Non-Reimbursable Procedures
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.344499,1341.696,other,Non-Reimbursable Procedures
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.344499,1347.84,other,Non-Reimbursable Procedures
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,139.8635,575,other,Non-Reimbursable Procedures
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2374.656,other,Non-Reimbursable Procedures
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,189.029,836,percent of total billed charges,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,189.029,836,percent of total billed charges,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,547.9266,399.547552,1936.896,percent of total billed charges,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,652.4414,399.547552,1936.896,percent of total billed charges,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,721.2556,399.547552,2548.224,percent of total billed charges,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.3666,399.547552,2548.224,percent of total billed charges,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,72.0645,416.02,other,Non-Reimbursable Procedures
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,88.2285,416.02,other,Non-Reimbursable Procedures
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.99364,416.02,other,Non-Reimbursable Procedures
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.6691,88.2285,416.02,percent of total billed charges,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,120.5542,90.800319,416.02,percent of total billed charges,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,120.5542,90.800319,416.02,percent of total billed charges,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.7794,58.819,416.02,percent of total billed charges,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.3966,48.941,416.02,percent of total billed charges,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.8674,76.026473,416.02,percent of total billed charges,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.8674,112.699,416.02,percent of total billed charges,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.8674,112.699,416.02,percent of total billed charges,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.8674,76.026473,416.02,percent of total billed charges,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,148.7525,119.991125,441.6,percent of total billed charges,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.4918,25.593,416.02,percent of total billed charges,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,312.36,,,312.36,267.439885,1847.808,fee schedule,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,55.676,416.02,other,Non-Reimbursable Procedures
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,55.676,416.02,other,Non-Reimbursable Procedures
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.8845,209.9075,1076.394,percent of total billed charges,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,163.7571,142.1085,1076.394,percent of total billed charges,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,254.0434,220.459,1076.394,percent of total billed charges,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,271.3763,235.5005,1397.122,percent of total billed charges,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.2377,38.3895,416.02,percent of total billed charges,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,407.4525,353.5875,1209.6,percent of total billed charges,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,351.0559,304.6465,1076.394,percent of total billed charges,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,491.0126,358.69,1457.664,percent of total billed charges,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,769.3738,399.86,3675.6585,percent of total billed charges,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,362.9561,314.9735,1077.504,percent of total billed charges,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,362.9561,314.9735,1077.504,percent of total billed charges,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.4833,147.9455,1076.394,percent of total billed charges,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,251.1977,217.9895,1076.394,percent of total billed charges,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,277.0677,240.4395,1397.122,percent of total billed charges,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,576.3836,399.86,2239.93036,percent of total billed charges,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,311.7335,270.5225,1076.394,percent of total billed charges,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,358.0408,310.708,1076.394,percent of total billed charges,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,358.0408,310.708,1397.122,percent of total billed charges,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.8556,176.906,1076.394,percent of total billed charges,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,269.8241,234.1535,1076.394,percent of total billed charges,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,216.7906,188.131,1076.394,percent of total billed charges,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,537.8373,399.86,1596.672,percent of total billed charges,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,231.0191,200.4785,1076.394,percent of total billed charges,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,246.7998,214.173,1076.394,percent of total billed charges,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,248.8694,215.969,1076.394,percent of total billed charges,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,284.0526,246.501,1076.394,percent of total billed charges,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,231.0191,200.4785,1076.394,percent of total billed charges,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,247.3172,214.622,1076.394,percent of total billed charges,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1166.737,399.86,3675.6585,percent of total billed charges,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1166.737,399.86,3675.6585,percent of total billed charges,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1008.93,399.86,3675.6585,percent of total billed charges,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1008.93,399.86,3675.6585,percent of total billed charges,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,410.2982,356.057,1218.048,percent of total billed charges,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,432.2877,375.1395,1283.328,percent of total billed charges,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,198.4229,172.1915,1076.394,percent of total billed charges,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,165.568,143.68,1076.394,percent of total billed charges,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.7302,212.377,1397.122,percent of total billed charges,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,233.3474,202.499,1076.394,percent of total billed charges,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,387.7913,336.5255,1397.122,percent of total billed charges,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,699.5248,399.86,2076.672,percent of total billed charges,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.0743,356.7305,1397.122,percent of total billed charges,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1265.043,399.86,3755.52,percent of total billed charges,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,664.859,399.86,1973.76,percent of total billed charges,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.9692,205.642,1397.122,percent of total billed charges,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,831.7205,399.86,3675.6585,percent of total billed charges,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,334.2404,290.054,1076.394,percent of total billed charges,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,313.027,271.645,1397.122,percent of total billed charges,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,232.5713,201.8255,1397.122,percent of total billed charges,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,218.6015,189.7025,1076.394,percent of total billed charges,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,224.2929,194.6415,1076.394,percent of total billed charges,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,808.1788,399.86,3675.6585,percent of total billed charges,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,625.7953,399.86,3675.6585,percent of total billed charges,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,754.3692,399.86,3675.6585,percent of total billed charges,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,317.4249,275.4615,1076.394,percent of total billed charges,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1341.6182,399.86,3982.848,percent of total billed charges,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1786.0648,399.86,5302.272,percent of total billed charges,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1993.2835,399.86,5917.44,percent of total billed charges,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.0666,399.86,3675.6585,percent of total billed charges,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.0666,399.86,3675.6585,percent of total billed charges,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1267.3713,399.86,4124.5085,percent of total billed charges,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.5161,45.5735,416.02,percent of total billed charges,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,202.3034,175.559,691.5815,percent of total billed charges,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.2784,2.29,24.576,percent of total billed charges,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.2436,6.286,21.504,percent of total billed charges,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,185.2292,160.742,549.888,percent of total billed charges,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.2088,3.33,18.432,percent of total billed charges,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.6415,2.4,34.56,percent of total billed charges,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,268.5306,39.73,1313.895373,percent of total billed charges,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.696,4.35,61.44,percent of total billed charges,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.2784,6.78,24.576,percent of total billed charges,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.4675,5.6125,19.2,percent of total billed charges,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.1136,18.77,98.304,percent of total billed charges,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.8746,6.51,121.344,percent of total billed charges,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.5023,6.5105,24.43,percent of total billed charges,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.5371,7.4085,25.344,percent of total billed charges,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.0985,14.71,119.04,percent of total billed charges,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.1924,26.37,193.536,percent of total billed charges,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.0788,27.838,95.232,percent of total billed charges,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,64.4315,241.472,percent of total billed charges,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.6113,6.25,92.88556,percent of total billed charges,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,2.072,274.944,percent of total billed charges,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.6087,2.842,549.235176,percent of total billed charges,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.2679,5.5,93.463636,percent of total billed charges,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,5.85,274.176,percent of total billed charges,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,5.29,274.176,percent of total billed charges,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.8096,3.05,195.186327,percent of total billed charges,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.9895,3.05,65.28,percent of total billed charges,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,162.4636,3.91,549.235176,percent of total billed charges,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.4557,9.71,238.848,percent of total billed charges,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,162.4636,3.91,549.235176,percent of total billed charges,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,73.4708,7.91,218.112,percent of total billed charges,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.8385,2.31,272.64,percent of total billed charges,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,2.072,274.176,percent of total billed charges,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,2.45,274.176,percent of total billed charges,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.862,274.176,other,Non-Reimbursable Procedures
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.7144,1.302,263.69806,percent of total billed charges,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.0092,1.932,416.02,percent of total billed charges,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.457,1.932,93.463636,percent of total billed charges,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,144.872,1.54,499.62884,percent of total billed charges,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,2.702,274.944,percent of total billed charges,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,2.072,608.812631,percent of total billed charges,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.4557,2.31,238.848,percent of total billed charges,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.6783,2.31,416.02,percent of total billed charges,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.6783,2.31,416.02,percent of total billed charges,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.4557,2.31,238.848,percent of total billed charges,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,77.3513,1.68,229.632,percent of total billed charges,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.4524,11.674,39.936,percent of total billed charges,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.327,47.145,416.02,percent of total billed charges,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,39.3224,34.124,116.736,percent of total billed charges,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.0046,12.32,44.544,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,168.274002,139.93,1690.176,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,569.334025,139.93,1690.176,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,168.274002,139.93,1690.176,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,569.334025,139.93,1690.176,percent of total billed charges,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,402.076714,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,402.076714,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2010.380983,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2010.380983,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1206.230142,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1206.230142,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,478.703654,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,478.703654,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2393.505335,287.71,7105.5744,percent of total billed charges,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2393.505335,287.71,7105.5744,percent of total billed charges,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1299.975261,389.10344,4791.979,percent of total billed charges,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.57677,0.5,416.02,percent of total billed charges,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.57677,0.5,416.02,percent of total billed charges,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.302776,0.5,416.02,percent of total billed charges,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.9291,43.3285,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.8851,16.3885,416.02,percent of total billed charges,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.7157,24.9195,416.02,percent of total billed charges,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.209867,0.5,671.54688,percent of total billed charges,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.209867,0.5,671.54688,percent of total billed charges,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.339707,70.48,416.02,percent of total billed charges,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.339707,70.48,416.02,percent of total billed charges,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.101087,34.799745,416.02,percent of total billed charges,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.101087,34.799745,416.02,percent of total billed charges,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.764258,11.07683,416.02,percent of total billed charges,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.764258,11.07683,416.02,percent of total billed charges,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.772879,0.5,881.02656,percent of total billed charges,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.772879,0.5,881.02656,percent of total billed charges,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.385062,0.5,416.02,percent of total billed charges,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.385062,0.5,416.02,percent of total billed charges,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,377.828763,91.911626,1316.02176,percent of total billed charges,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,443.300559,91.911626,1316.02176,percent of total billed charges,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,377.828763,91.911626,1316.02176,percent of total billed charges,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,284.15608,0.5,843.5712,percent of total billed charges,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.522616,0.5,416.02,percent of total billed charges,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.522616,0.5,416.02,percent of total billed charges,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.812837,24.135995,416.02,percent of total billed charges,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.812837,24.135995,416.02,percent of total billed charges,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.786511,54.47,416.02,percent of total billed charges,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.786511,54.47,416.02,percent of total billed charges,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.338842,25.298577,416.02,percent of total billed charges,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.338842,25.298577,416.02,percent of total billed charges,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.130886,25.298577,416.02,percent of total billed charges,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,48.617491,25.298577,416.02,percent of total billed charges,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.130886,25.298577,416.02,percent of total billed charges,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,48.617491,25.298577,416.02,percent of total billed charges,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.692944,0.5,566.10816,percent of total billed charges,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.692944,0.5,566.10816,percent of total billed charges,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.531989,0.5,416.02,percent of total billed charges,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.531989,0.5,416.02,percent of total billed charges,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,165.777547,0.5,492.14208,percent of total billed charges,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,165.777547,0.5,492.14208,percent of total billed charges,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,139.059011,0.5,416.02,percent of total billed charges,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,139.059011,0.5,416.02,percent of total billed charges,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,291.2962,252.787,1055.807021,percent of total billed charges,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,459.1925,398.4875,1363.2,percent of total billed charges,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1014.6214,399.86,3012.096,percent of total billed charges,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1014.6214,399.86,3012.096,percent of total billed charges,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,194.5424,168.824,1592,percent of total billed charges,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,351.832,305.32,1592,percent of total billed charges,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,127.466664,0.5,417.629472,percent of total billed charges,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,127.466664,0.5,417.629472,percent of total billed charges,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.96,416.02,other,Non-Reimbursable Procedures
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,328.549,163,975.36,percent of total billed charges,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,228.1734,163,677.376,percent of total billed charges,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,142.285,123.475,422.4,percent of total billed charges,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.0985,34.7975,416.02,percent of total billed charges,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.0985,34.7975,416.02,percent of total billed charges,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.0985,34.7975,416.02,percent of total billed charges,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.0552,142.97,534.528,percent of total billed charges,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,58.2075,50.5125,416.02,percent of total billed charges,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.5903,60.3905,416.02,percent of total billed charges,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,59.501,51.635,416.02,percent of total billed charges,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.3165,61.17,416.02,percent of total billed charges,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.2528,32.328,416.02,percent of total billed charges,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.1484,29.634,416.02,percent of total billed charges,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,134.2653,116.5155,416.02,percent of total billed charges,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.0545,7.8575,416.02,percent of total billed charges,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.5765,21.3275,416.02,percent of total billed charges,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.3375,28.0625,416.02,percent of total billed charges,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.8733,80.5955,416.02,percent of total billed charges,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.35,112.25,416.02,percent of total billed charges,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,132.1957,114.7195,416.02,percent of total billed charges,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.4918,25.593,416.02,percent of total billed charges,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,161.4288,128.12716,479.602522,percent of total billed charges,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.0092,26.042,416.02,percent of total billed charges,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.9094,36.369,416.02,percent of total billed charges,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.5923,84.99,559.872,percent of total billed charges,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.5614,20.01,416.02,percent of total billed charges,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,223.2581,128.12716,662.784,percent of total billed charges,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,223.2581,128.12716,662.784,percent of total billed charges,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4543.5481,399.86,13488.384,percent of total billed charges,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13488.384,other,Non-Reimbursable Procedures
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8662.3108,399.86,25715.712,percent of total billed charges,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,25231.872,other,Non-Reimbursable Procedures
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8429.4808,399.86,25024.512,percent of total billed charges,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,20484.864,other,Non-Reimbursable Procedures
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26793.51305,percent of total billed charges,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6769.9203,399.86,20097.792,percent of total billed charges,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6900.3051,399.86,20484.864,percent of total billed charges,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,20097.792,other,Non-Reimbursable Procedures
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6640.0529,399.86,19712.256,percent of total billed charges,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,20097.792,other,Non-Reimbursable Procedures
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.133,997.822944,other,Non-Reimbursable Procedures
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.133,997.822944,other,Non-Reimbursable Procedures
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,336.8274,292.299,999.936,percent of total billed charges,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,518.9522,399.86,1540.608,percent of total billed charges,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,518.9522,399.86,1540.608,percent of total billed charges,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,199.9751,173.5385,593.664,percent of total billed charges,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,2138.88,other,Non-Reimbursable Procedures
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,2138.88,other,Non-Reimbursable Procedures
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,169.4975,1592,other,Non-Reimbursable Procedures
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,169.4975,1592,other,Non-Reimbursable Procedures
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4457.6597,399.86,13233.408,percent of total billed charges,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4457.6597,399.86,16809.6787,percent of total billed charges,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4457.6597,399.86,16809.6787,percent of total billed charges,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.6159,25.49469,416.02,percent of total billed charges,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,6.286,416.02,other,Non-Reimbursable Procedures
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,125.4695,108.8825,479.602522,percent of total billed charges,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.044,25.49469,416.02,percent of total billed charges,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.939,416.02,other,Non-Reimbursable Procedures
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,112.0171,84.459332,416.02,percent of total billed charges,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.2666,66.75974,416.02,percent of total billed charges,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.1435,416.02,other,Non-Reimbursable Procedures
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,314.8379,41.157815,934.656,percent of total billed charges,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,485.8386,41.157815,1442.304,percent of total billed charges,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.9488,41.157815,416.02,percent of total billed charges,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.1576,23.39896,416.02,percent of total billed charges,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,345.8819,54.1045,1223.3,percent of total billed charges,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,1223.3,percent of total billed charges,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,337.0861,281.81,1040.64,percent of total billed charges,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,350.5385,281.81,1040.64,percent of total billed charges,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,348.4689,54.1045,1034.496,percent of total billed charges,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,348.4689,54.1045,1034.496,percent of total billed charges,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,1034.496,percent of total billed charges,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,317.6836,267.439885,943.104,percent of total billed charges,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,317.6836,267.439885,943.104,percent of total billed charges,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,145.1307,125.9445,465.66,percent of total billed charges,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,145.1307,125.9445,465.66,percent of total billed charges,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,145.1307,125.9445,465.66,percent of total billed charges,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,456.3468,224.549385,1354.752,percent of total billed charges,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,456.3468,224.549385,1354.752,percent of total billed charges,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,388.3087,336.9745,1152.768,percent of total billed charges,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.024,416.02,other,Non-Reimbursable Procedures
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,72.5135,416.02,other,Non-Reimbursable Procedures
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,86.208,416.02,other,Non-Reimbursable Procedures
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,135.906309,571.392,other,Non-Reimbursable Procedures
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,358.0408,224.549385,1062.912,percent of total billed charges,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,358.0408,224.549385,1062.912,percent of total billed charges,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,461.7795,224.549385,1370.88,percent of total billed charges,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,461.7795,224.549385,1370.88,percent of total billed charges,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,201.2686,174.661,597.504,percent of total billed charges,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,278.6199,241.7865,827.136,percent of total billed charges,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2374.0899,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2523.6185,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2523.6185,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2681.4255,399.86,7960.32,percent of total billed charges,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,775.5826,399.86,2532.39,percent of total billed charges,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,775.5826,399.86,2532.39,percent of total billed charges,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,657.6154,399.86,1952.256,percent of total billed charges,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,263.3566,228.541,1592,percent of total billed charges,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.937,114.495,1592,percent of total billed charges,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,263.3566,228.541,1592,percent of total billed charges,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,387.5326,235.074116,1592,percent of total billed charges,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5638.7,other,Non-Reimbursable Procedures
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1575.168,other,Non-Reimbursable Procedures
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13776.8098,399.86,40899.072,percent of total billed charges,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13776.8098,399.86,40899.072,percent of total billed charges,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13656.773,399.86,40542.72,percent of total billed charges,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13656.773,399.86,40542.72,percent of total billed charges,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4371.7713,399.86,12978.432,percent of total billed charges,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6909.98,other,Non-Reimbursable Procedures
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4525.056,other,Non-Reimbursable Procedures
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2361.6,other,Non-Reimbursable Procedures
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,797.5721,399.86,2367.744,percent of total billed charges,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,797.5721,399.86,2367.744,percent of total billed charges,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10671.09667,other,Non-Reimbursable Procedures
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,314.8379,73.54,934.656,percent of total billed charges,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.9685,57.2475,416.02,percent of total billed charges,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,70.1077,60.8395,416.02,percent of total billed charges,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,199.512292,702.72,percent of total billed charges,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,119.991125,702.72,percent of total billed charges,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,294.1419,255.2565,873.216,percent of total billed charges,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,110.7236,96.086,686,percent of total billed charges,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,246.2824,213.724,731.136,percent of total billed charges,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,135.906309,702.72,percent of total billed charges,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.3487,121.132463,686,percent of total billed charges,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,135.906309,775.5705,percent of total billed charges,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,199.512292,702.72,percent of total billed charges,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.0867,99.0045,686,percent of total billed charges,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,135.906309,686,percent of total billed charges,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,135.906309,686,percent of total billed charges,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,119.991125,702.72,percent of total billed charges,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,196.0946,170.171,686,percent of total billed charges,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,196.0946,170.171,686,percent of total billed charges,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,119.991125,702.72,percent of total billed charges,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,211.0992,183.192,686,percent of total billed charges,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,108.1366,93.841,686,percent of total billed charges,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,199.512292,702.72,percent of total billed charges,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,100.1169,86.8815,686,percent of total billed charges,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,158.8418,119.991125,686,percent of total billed charges,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.3165,66.2275,416.02,percent of total billed charges,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.3802,100.127,479.602522,percent of total billed charges,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,239.2975,163,710.4,percent of total billed charges,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.4104,88.004,416.02,percent of total billed charges,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.4104,88.004,416.02,percent of total billed charges,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.0834,40.859,416.02,percent of total billed charges,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,127.7978,59.92,416.02,percent of total billed charges,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.3802,98.67,479.602522,percent of total billed charges,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.3165,66.2275,416.02,percent of total billed charges,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.5555,59.4925,416.02,percent of total billed charges,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.123,416.02,other,Non-Reimbursable Procedures
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.205,416.02,other,Non-Reimbursable Procedures
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.1878,43.553,416.02,percent of total billed charges,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,43.553,416.02,other,Non-Reimbursable Procedures
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,94.9429,22.74,416.02,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.9449,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.9449,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.9449,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,426.5963,370.2005,1266.432,percent of total billed charges,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,410.0395,355.8325,1217.28,percent of total billed charges,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,410.0395,355.8325,1217.28,percent of total billed charges,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,210.0644,182.294,623.616,percent of total billed charges,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,247.8346,215.071,735.744,percent of total billed charges,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.3487,157.3745,538.368,percent of total billed charges,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.3382,176.457,603.648,percent of total billed charges,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,174.6225,151.5375,518.4,percent of total billed charges,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,174.6225,151.5375,829.50194,percent of total billed charges,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.8884,14.817,570,percent of total billed charges,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.0742,14.817,570,percent of total billed charges,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.8884,30.083,570,percent of total billed charges,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.6658,30.083,570,percent of total billed charges,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.566,20.4295,570,percent of total billed charges,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.5417,20.4295,570,percent of total billed charges,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,196.612,94.4,583.68,percent of total billed charges,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.0552,94.4,570,percent of total billed charges,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.2988,94.4,570,percent of total billed charges,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,227.3973,197.3355,675.072,percent of total billed charges,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,156.252,534.528,other,Non-Reimbursable Procedures
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.4058,74.983,416.02,percent of total billed charges,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.0243,19.9805,585.854902,percent of total billed charges,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,108.1366,93.841,416.02,percent of total billed charges,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.1484,29.634,585.854902,percent of total billed charges,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.3421,41.0835,416.02,percent of total billed charges,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.4705,416.02,other,Non-Reimbursable Procedures
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.9094,16.16,416.02,percent of total billed charges,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.4058,74.983,416.02,percent of total billed charges,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.9383,69.3705,416.02,percent of total billed charges,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.1635,23.5725,416.02,percent of total billed charges,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,68.0235,416.02,other,Non-Reimbursable Procedures
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.4314,49.839,416.02,percent of total billed charges,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,178.7617,155.1295,530.688,percent of total billed charges,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.2988,162.538,556.032,percent of total billed charges,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,48.3769,41.9815,585.854902,percent of total billed charges,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,172.8116,70.143083,517.481916,percent of total billed charges,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,169.9659,147.4965,585.854902,percent of total billed charges,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.111,34.385146,416.02,percent of total billed charges,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,63.3815,14.38,416.02,percent of total billed charges,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.8201,27.6135,416.02,percent of total billed charges,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.8201,14.73,416.02,percent of total billed charges,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.8595,20.02,416.02,percent of total billed charges,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,14.44,416.02,percent of total billed charges,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,14.44,416.02,percent of total billed charges,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.9639,30.33,416.02,percent of total billed charges,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.9639,30.33,416.02,percent of total billed charges,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,25.8175,416.02,other,Non-Reimbursable Procedures
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.218,27.89,416.02,percent of total billed charges,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.218,27.89,416.02,percent of total billed charges,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.631,18.56,416.02,percent of total billed charges,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.631,18.56,416.02,percent of total billed charges,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.262,58.37,416.02,percent of total billed charges,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.262,58.37,416.02,percent of total billed charges,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.262,58.37,416.02,percent of total billed charges,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.8595,416.02,other,Non-Reimbursable Procedures
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.9048,23.348,416.02,percent of total billed charges,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.0834,34.45,416.02,percent of total billed charges,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.4222,23.797,416.02,percent of total billed charges,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.4524,11.674,416.02,percent of total billed charges,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.635,416.02,other,Non-Reimbursable Procedures
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,53.88,416.02,other,Non-Reimbursable Procedures
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,53.88,416.02,other,Non-Reimbursable Procedures
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,81.0445,416.02,other,Non-Reimbursable Procedures
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,53.88,416.02,other,Non-Reimbursable Procedures
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,74.085,416.02,other,Non-Reimbursable Procedures
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.7144,70.044,416.02,percent of total billed charges,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,100.1169,82.56,416.02,percent of total billed charges,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,148.2351,126.37,473.871,percent of total billed charges,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,216.7906,179.35,693.026,percent of total billed charges,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.3704,146.954008,985.784,percent of total billed charges,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,18.1184,416.02,percent of total billed charges,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,18.1184,416.02,percent of total billed charges,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,18.1184,416.02,percent of total billed charges,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.9278,50.2428,416.02,percent of total billed charges,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.9278,50.2428,416.02,percent of total billed charges,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,96.4951,50.2428,416.02,percent of total billed charges,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.4997,90.68,416.02,percent of total billed charges,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.4997,90.68,416.02,percent of total billed charges,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,120.8129,104.8415,416.02,percent of total billed charges,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,120.8129,104.8415,416.02,percent of total billed charges,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,214.4623,169.273,685.583,percent of total billed charges,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.0598,169.273,685.583,percent of total billed charges,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,816.7159,318.748996,2424.576,percent of total billed charges,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,816.7159,318.748996,2424.576,percent of total billed charges,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,204.5195,699.648,other,Non-Reimbursable Procedures
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,204.5195,699.648,other,Non-Reimbursable Procedures
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.31797,416.02,other,Non-Reimbursable Procedures
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.3618,31.31797,416.02,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,200.2338,173.763,2998,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.6507,36.1445,2998,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,22389.354,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.1445,165.0075,2998,percent of total billed charges,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.1,1477.69344,other,Non-Reimbursable Procedures
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.30904,416.02,other,Non-Reimbursable Procedures
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.850175,416.02,other,Non-Reimbursable Procedures
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.025285,416.02,other,Non-Reimbursable Procedures
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.025285,416.02,other,Non-Reimbursable Procedures
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.025285,416.02,other,Non-Reimbursable Procedures
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.025285,416.02,other,Non-Reimbursable Procedures
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.401765,416.02,other,Non-Reimbursable Procedures
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.401765,416.02,other,Non-Reimbursable Procedures
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.99,416.02,other,Non-Reimbursable Procedures
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.3553,416.02,other,Non-Reimbursable Procedures
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.3553,416.02,other,Non-Reimbursable Procedures
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.3553,416.02,other,Non-Reimbursable Procedures
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,5.23,416.02,other,Non-Reimbursable Procedures
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.98576,416.02,other,Non-Reimbursable Procedures
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.98576,416.02,other,Non-Reimbursable Procedures
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.94544,416.02,other,Non-Reimbursable Procedures
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.94544,416.02,other,Non-Reimbursable Procedures
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.94544,416.02,other,Non-Reimbursable Procedures
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.94544,416.02,other,Non-Reimbursable Procedures
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.121435,416.02,other,Non-Reimbursable Procedures
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.121435,416.02,other,Non-Reimbursable Procedures
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.692165,416.02,other,Non-Reimbursable Procedures
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.206745,416.02,other,Non-Reimbursable Procedures
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.206745,416.02,other,Non-Reimbursable Procedures
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.04041,416.02,other,Non-Reimbursable Procedures
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.04041,416.02,other,Non-Reimbursable Procedures
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.04041,416.02,other,Non-Reimbursable Procedures
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.04041,416.02,other,Non-Reimbursable Procedures
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.913715,416.02,other,Non-Reimbursable Procedures
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.913715,416.02,other,Non-Reimbursable Procedures
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.913715,416.02,other,Non-Reimbursable Procedures
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.913715,416.02,other,Non-Reimbursable Procedures
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.67604,416.02,other,Non-Reimbursable Procedures
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,416.02,other,Non-Reimbursable Procedures
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,416.02,other,Non-Reimbursable Procedures
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,416.02,other,Non-Reimbursable Procedures
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.600005,416.02,other,Non-Reimbursable Procedures
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.600005,416.02,other,Non-Reimbursable Procedures
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.600005,416.02,other,Non-Reimbursable Procedures
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.087465,416.02,other,Non-Reimbursable Procedures
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.66833,416.02,other,Non-Reimbursable Procedures
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.66833,416.02,other,Non-Reimbursable Procedures
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.122795,416.02,other,Non-Reimbursable Procedures
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.122795,416.02,other,Non-Reimbursable Procedures
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.98009,416.02,other,Non-Reimbursable Procedures
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.21357,416.02,other,Non-Reimbursable Procedures
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.12,416.02,other,Non-Reimbursable Procedures
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.994945,416.02,other,Non-Reimbursable Procedures
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11462.94267,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7977.66125,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8885.116175,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8885.116175,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8885.116175,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8885.116175,399.86,37344.8064,percent of total billed charges,
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9605.531,399.86,37344.8064,percent of total billed charges,
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9605.531,399.86,37344.8064,percent of total billed charges,
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6765.05674,399.86,37344.8064,percent of total billed charges,
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6765.05674,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6719.742848,399.86,37344.8064,percent of total billed charges,
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9506.593772,399.86,37344.8064,percent of total billed charges,
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6701.23545,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6491.264182,399.86,37344.8064,percent of total billed charges,
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6491.264182,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12579.55914,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9235.802134,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8252.985312,399.86,37344.8064,percent of total billed charges,
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6701.23545,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8852.012923,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9721.896847,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8472.277541,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8472.277541,399.86,37344.8064,percent of total billed charges,
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7216.273519,399.86,37344.8064,percent of total billed charges,
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7216.273519,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8296.7677,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8296.7677,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9637.01479,399.86,37344.8064,percent of total billed charges,
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8998.80189,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8998.80189,399.86,37344.8064,percent of total billed charges,
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9956.12124,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11806.93865,399.86,37344.8064,percent of total billed charges,
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8510.570315,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11175.10788,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10833.66527,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6638.689551,399.86,37344.8064,percent of total billed charges,
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,291.097925,929.69805,other,Non-Reimbursable Procedures
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.523743,1.322305,17969.99175,percent of total billed charges,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.523743,1.322305,17969.99175,percent of total billed charges,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,72522.399,other,Non-Reimbursable Procedures
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,72522.399,other,Non-Reimbursable Procedures
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,14791.55236,percent of total billed charges,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,14243.66592,percent of total billed charges,
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3453.189688,399.86,14243.66592,percent of total billed charges,
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2935.450791,399.86,14243.66592,percent of total billed charges,
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,14243.66592,percent of total billed charges,
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,14243.66592,percent of total billed charges,
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4562.627225,399.86,14243.66592,percent of total billed charges,
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4461.770443,399.86,14243.66592,percent of total billed charges,
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4797.964028,399.86,14243.66592,percent of total billed charges,
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,14243.66592,percent of total billed charges,
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,14243.66592,percent of total billed charges,
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,247.50227,1378.95936,other,Non-Reimbursable Procedures
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,247.50227,1378.95936,other,Non-Reimbursable Procedures
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,247.50227,1378.95936,other,Non-Reimbursable Procedures
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9509.47569,399.86,39874.22976,percent of total billed charges,
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,514.215403,399.86,39874.22976,percent of total billed charges,
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10453.9273,399.86,39874.22976,percent of total billed charges,
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11896.28846,399.86,39874.22976,percent of total billed charges,
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11641.0033,399.86,39874.22976,percent of total billed charges,
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13431.59276,399.86,39874.22976,percent of total billed charges,
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7658.5548,399.86,39874.22976,percent of total billed charges,
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6988.025096,399.86,39874.22976,percent of total billed charges,
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13053.36819,399.86,39874.22976,percent of total billed charges,
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8424.41028,399.86,39874.22976,percent of total billed charges,
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11480.17468,399.86,39874.22976,percent of total billed charges,
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6858.235306,399.86,39874.22976,percent of total billed charges,
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,144.095325,460.20645,other,Non-Reimbursable Procedures
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7525.805482,399.86,23012.49024,percent of total billed charges,
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7525.805482,399.86,23012.49024,percent of total billed charges,
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7751.733366,399.86,23012.49024,percent of total billed charges,
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7751.733366,399.86,23012.49024,percent of total billed charges,
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2785.60399,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2272.700196,9.170825,27238.33344,percent of total billed charges,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,102.646986,9.170825,27238.33344,percent of total billed charges,
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1775.000201,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4780.095619,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2707.47659,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2707.47659,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4103.915907,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5019.851018,9.170825,27238.33344,percent of total billed charges,
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5019.851018,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,835.500107,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1169.701702,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4202.421106,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3132.844065,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2809.619111,9.170825,27238.33344,percent of total billed charges,
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,271.71261,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1396.558319,9.170825,27238.33344,percent of total billed charges,
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1396.558319,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1396.558319,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2508.337091,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1200.029103,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2094.836185,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2094.836185,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1800.593392,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3671.234983,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3671.234983,9.170825,27238.33344,percent of total billed charges,
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4289.830662,9.170825,27238.33344,percent of total billed charges,
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1119.881256,9.170825,27238.33344,percent of total billed charges,
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1119.881256,9.170825,27238.33344,percent of total billed charges,
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1119.881256,9.170825,27238.33344,percent of total billed charges,
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1271.942529,9.170825,27238.33344,percent of total billed charges,
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1119.881256,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.475725,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.475725,9.170825,27238.33344,percent of total billed charges,
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5567.366285,9.170825,27238.33344,percent of total billed charges,
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5567.366285,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5567.366285,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,815.122308,9.170825,27238.33344,percent of total billed charges,
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2530.16361,9.170825,27238.33344,percent of total billed charges,
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2530.16361,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3786.501355,9.170825,27238.33344,percent of total billed charges,
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5498.205427,9.170825,27238.33344,percent of total billed charges,
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4301.355747,9.170825,27238.33344,percent of total billed charges,
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3584.785204,9.170825,27238.33344,percent of total billed charges,
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1976.26104,9.170825,27238.33344,percent of total billed charges,
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3602.074125,9.170825,27238.33344,percent of total billed charges,
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3602.074125,9.170825,27238.33344,percent of total billed charges,
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3584.785204,9.170825,27238.33344,percent of total billed charges,
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2690.749048,9.170825,27238.33344,percent of total billed charges,
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,191.520784,9.170825,27238.33344,percent of total billed charges,
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2129.970232,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,94.948074,9.170825,27238.33344,percent of total billed charges,
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,199.255914,9.170825,27238.33344,percent of total billed charges,
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.541349,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1335.07309,9.170825,27238.33344,percent of total billed charges,
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1335.07309,9.170825,27238.33344,percent of total billed charges,
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1335.07309,9.170825,27238.33344,percent of total billed charges,
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6828.572764,9.170825,27238.33344,percent of total billed charges,
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1778.634936,9.170825,27238.33344,percent of total billed charges,
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,386.689238,9.170825,27238.33344,percent of total billed charges,
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1877.996432,9.170825,27238.33344,percent of total billed charges,
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1877.996432,9.170825,27238.33344,percent of total billed charges,
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5868.019664,9.170825,27238.33344,percent of total billed charges,
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.430155,9.170825,27238.33344,percent of total billed charges,
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1638.101335,9.170825,27238.33344,percent of total billed charges,
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1887.330328,9.170825,27238.33344,percent of total billed charges,
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1942.226468,9.170825,27238.33344,percent of total billed charges,
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1976.26104,9.170825,27238.33344,percent of total billed charges,
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,953.446611,9.170825,27238.33344,percent of total billed charges,
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1254.035315,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1291.66323,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1291.66323,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1587.872143,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1607.854131,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1254.035315,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1217.51981,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4149.589392,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2664.395279,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2664.395279,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2718.846455,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2664.395279,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3393.538642,9.170825,27238.33344,percent of total billed charges,
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3393.538642,9.170825,27238.33344,percent of total billed charges,
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1399.85157,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2761.591456,9.170825,27238.33344,percent of total billed charges,
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2525.22244,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2750.350941,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2750.350941,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2750.350941,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2750.350941,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7231.042702,9.170825,27238.33344,percent of total billed charges,
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7231.042702,9.170825,27238.33344,percent of total billed charges,
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7231.042702,9.170825,27238.33344,percent of total billed charges,
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7231.042702,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,438.796592,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,438.796592,9.170825,27238.33344,percent of total billed charges,
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,287.961557,9.170825,27238.33344,percent of total billed charges,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.167521,9.170825,27238.33344,percent of total billed charges,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.167521,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,500.227494,9.170825,27238.33344,percent of total billed charges,
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,665.050438,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1139.75459,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2215.387798,9.170825,27238.33344,percent of total billed charges,
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1139.75459,9.170825,27238.33344,percent of total billed charges,
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3134.6679,9.170825,27238.33344,percent of total billed charges,
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1160.931772,9.170825,27238.33344,percent of total billed charges,
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,722.494773,9.170825,27238.33344,percent of total billed charges,
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,113.214881,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1864.272397,9.170825,27238.33344,percent of total billed charges,
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1864.272397,9.170825,27238.33344,percent of total billed charges,
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,293.888374,9.170825,27238.33344,percent of total billed charges,
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1864.272397,9.170825,27238.33344,percent of total billed charges,
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1506.899043,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1506.899043,9.170825,27238.33344,percent of total billed charges,
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2482.068693,9.170825,27238.33344,percent of total billed charges,
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2482.068693,9.170825,27238.33344,percent of total billed charges,
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2482.068693,9.170825,27238.33344,percent of total billed charges,
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2697.23207,9.170825,27238.33344,percent of total billed charges,
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3181.352902,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3181.352902,9.170825,27238.33344,percent of total billed charges,
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3181.352902,9.170825,27238.33344,percent of total billed charges,
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3181.352902,9.170825,27238.33344,percent of total billed charges,
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1932.344128,9.170825,27238.33344,percent of total billed charges,
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1932.344128,9.170825,27238.33344,percent of total billed charges,
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4994.87612,9.170825,27238.33344,percent of total billed charges,
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5286.883745,9.170825,27238.33344,percent of total billed charges,
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1914.778398,9.170825,27238.33344,percent of total billed charges,
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1914.778398,9.170825,27238.33344,percent of total billed charges,
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6274.812479,9.170825,27238.33344,percent of total billed charges,
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6969.284868,9.170825,27238.33344,percent of total billed charges,
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6969.284868,9.170825,27238.33344,percent of total billed charges,
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9175.204246,9.170825,27238.33344,percent of total billed charges,
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,647.226008,9.170825,27238.33344,percent of total billed charges,
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,449.765472,9.170825,27238.33344,percent of total billed charges,
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,879.344583,9.170825,27238.33344,percent of total billed charges,
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1809.376257,9.170825,27238.33344,percent of total billed charges,
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3116.996103,9.170825,27238.33344,percent of total billed charges,
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4744.172537,9.170825,27238.33344,percent of total billed charges,
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3489.976828,9.170825,27238.33344,percent of total billed charges,
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1144.310297,9.170825,27238.33344,percent of total billed charges,
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.553591,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,611.571974,9.170825,27238.33344,percent of total billed charges,
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1509.64385,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5042.903775,9.170825,27238.33344,percent of total billed charges,
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.392381,9.170825,27238.33344,percent of total billed charges,
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2480.149139,9.170825,27238.33344,percent of total billed charges,
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1328.486588,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1328.486588,9.170825,27238.33344,percent of total billed charges,
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2278.18981,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3388.830302,9.170825,27238.33344,percent of total billed charges,
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6918.227836,9.170825,27238.33344,percent of total billed charges,
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7377.741124,9.170825,27238.33344,percent of total billed charges,
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3534.835408,9.170825,27238.33344,percent of total billed charges,
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,810.181138,9.170825,27238.33344,percent of total billed charges,
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,879.344583,9.170825,27238.33344,percent of total billed charges,
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9175.204246,9.170825,27238.33344,percent of total billed charges,
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5609.630104,9.170825,27238.33344,percent of total billed charges,
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7689.190054,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.252418,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1136.231096,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1197.982786,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1197.982786,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,383.947018,9.170825,27238.33344,percent of total billed charges,
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1436.082505,9.170825,27238.33344,percent of total billed charges,
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2518.571263,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2472.463162,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3002.689508,9.170825,27238.33344,percent of total billed charges,
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1193.041616,9.170825,27238.33344,percent of total billed charges,
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1193.041616,9.170825,27238.33344,percent of total billed charges,
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1376.796226,9.170825,27238.33344,percent of total billed charges,
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1376.796226,9.170825,27238.33344,percent of total billed charges,
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1376.796226,9.170825,27238.33344,percent of total billed charges,
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7694.030331,9.170825,27238.33344,percent of total billed charges,
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7694.030331,9.170825,27238.33344,percent of total billed charges,
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,9.170825,27238.33344,percent of total billed charges,
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1671.039019,9.170825,27238.33344,percent of total billed charges,
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4629.529632,9.170825,27238.33344,percent of total billed charges,
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3942.205124,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,821.297477,9.170825,27238.33344,percent of total billed charges,
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1186.853512,9.170825,27238.33344,percent of total billed charges,
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,983.308352,9.170825,27238.33344,percent of total billed charges,
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2499.732729,9.170825,27238.33344,percent of total billed charges,
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7823.706293,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7823.706293,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5138.959085,9.170825,27238.33344,percent of total billed charges,
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3488.729894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3488.729894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3488.729894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3488.729894,9.170825,27238.33344,percent of total billed charges,
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9041.686589,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1514.036576,9.170825,27238.33344,percent of total billed charges,
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1514.036576,9.170825,27238.33344,percent of total billed charges,
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.475725,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2393.813188,9.170825,27238.33344,percent of total billed charges,
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.348156,9.170825,27238.33344,percent of total billed charges,
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5695.120106,9.170825,27238.33344,percent of total billed charges,
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5695.120106,9.170825,27238.33344,percent of total billed charges,
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2785.60399,9.170825,27238.33344,percent of total billed charges,
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2785.60399,9.170825,27238.33344,percent of total billed charges,
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1212.493269,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2318.813471,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2020.177952,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1674.33227,9.170825,27238.33344,percent of total billed charges,
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1037.428392,9.170825,27238.33344,percent of total billed charges,
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1179.457279,9.170825,27238.33344,percent of total billed charges,
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1179.457279,9.170825,27238.33344,percent of total billed charges,
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.19148,9.170825,27238.33344,percent of total billed charges,
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,71.098521,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,113.214881,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1160.931772,9.170825,27238.33344,percent of total billed charges,
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,438.796592,9.170825,27238.33344,percent of total billed charges,
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,329.097444,9.170825,27238.33344,percent of total billed charges,
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2517.536463,9.170825,27238.33344,percent of total billed charges,
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2517.536463,9.170825,27238.33344,percent of total billed charges,
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2517.536463,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8789.060865,9.170825,27238.33344,percent of total billed charges,
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8212.729005,9.170825,27238.33344,percent of total billed charges,
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2031.15718,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2031.15718,9.170825,27238.33344,percent of total billed charges,
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1399.85157,9.170825,27238.33344,percent of total billed charges,
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2881.6593,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2939.292486,9.170825,27238.33344,percent of total billed charges,
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2939.292486,9.170825,27238.33344,percent of total billed charges,
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1449.258096,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2121.187367,9.170825,27238.33344,percent of total billed charges,
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2996.925672,9.170825,27238.33344,percent of total billed charges,
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1415.267503,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1345.229652,9.170825,27238.33344,percent of total billed charges,
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.370311,9.170825,27238.33344,percent of total billed charges,
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,369.547776,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1684.21461,9.170825,27238.33344,percent of total billed charges,
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1684.21461,9.170825,27238.33344,percent of total billed charges,
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2069.584478,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3237.418366,9.170825,27238.33344,percent of total billed charges,
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3237.418366,9.170825,27238.33344,percent of total billed charges,
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3237.418366,9.170825,27238.33344,percent of total billed charges,
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1179.457279,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4923.133436,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1248.118846,9.170825,27238.33344,percent of total billed charges,
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,88.622859,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1674.33227,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8553.726649,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1674.33227,9.170825,27238.33344,percent of total billed charges,
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.306486,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.306486,9.170825,27238.33344,percent of total billed charges,
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3492.493979,9.170825,27238.33344,percent of total billed charges,
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3492.493979,9.170825,27238.33344,percent of total billed charges,
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3492.493979,9.170825,27238.33344,percent of total billed charges,
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3977.362454,9.170825,27238.33344,percent of total billed charges,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3977.649611,9.170825,27238.33344,percent of total billed charges,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3977.649611,9.170825,27238.33344,percent of total billed charges,
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3977.649611,9.170825,27238.33344,percent of total billed charges,
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3508.900733,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1238.973801,9.170825,27238.33344,percent of total billed charges,
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1238.973801,9.170825,27238.33344,percent of total billed charges,
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8319.349623,9.170825,27238.33344,percent of total billed charges,
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8061.267916,9.170825,27238.33344,percent of total billed charges,
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8735.269374,9.170825,27238.33344,percent of total billed charges,
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4389.727667,9.170825,27238.33344,percent of total billed charges,
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1124.93108,9.170825,27238.33344,percent of total billed charges,
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1124.93108,9.170825,27238.33344,percent of total billed charges,
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1124.93108,9.170825,27238.33344,percent of total billed charges,
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1167.316488,9.170825,27238.33344,percent of total billed charges,
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3510.822874,9.170825,27238.33344,percent of total billed charges,
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4831.582093,9.170825,27238.33344,percent of total billed charges,
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4389.727667,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.804874,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3287.013743,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3287.013743,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3287.013743,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3162.14184,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3908.49134,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1399.85157,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7077.398185,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1147.329326,9.170825,27238.33344,percent of total billed charges,
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1147.329326,9.170825,27238.33344,percent of total billed charges,
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1147.329326,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.405442,9.170825,27238.33344,percent of total billed charges,
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1147.329326,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.405442,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1190.14935,9.170825,27238.33344,percent of total billed charges,
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1190.14935,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1190.14935,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1190.14935,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1136.921825,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1136.921825,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4530.400966,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,211.33203,9.170825,27238.33344,percent of total billed charges,
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2584.511306,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.540788,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.540788,9.170825,27238.33344,percent of total billed charges,
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.540788,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2728.622728,9.170825,27238.33344,percent of total billed charges,
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3031.102529,9.170825,27238.33344,percent of total billed charges,
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3031.102529,9.170825,27238.33344,percent of total billed charges,
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3031.102529,9.170825,27238.33344,percent of total billed charges,
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6371.348971,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1040.193895,9.170825,27238.33344,percent of total billed charges,
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1360.875828,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1153.313057,9.170825,27238.33344,percent of total billed charges,
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1153.313057,9.170825,27238.33344,percent of total billed charges,
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1055.286453,9.170825,27238.33344,percent of total billed charges,
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1055.286453,9.170825,27238.33344,percent of total billed charges,
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1055.286453,9.170825,27238.33344,percent of total billed charges,
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3658.180981,9.170825,27238.33344,percent of total billed charges,
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3658.180981,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,929.907498,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5310.580665,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5310.580665,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5310.580665,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5310.580665,9.170825,27238.33344,percent of total billed charges,
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,889.594277,9.170825,27238.33344,percent of total billed charges,
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2911.570194,9.170825,27238.33344,percent of total billed charges,
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2911.570194,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,421.285189,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.358454,9.170825,27238.33344,percent of total billed charges,
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,777.639265,9.170825,27238.33344,percent of total billed charges,
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,777.639265,9.170825,27238.33344,percent of total billed charges,
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,650.55289,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3252.808429,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3252.808429,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3252.808429,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1296.537138,9.170825,27238.33344,percent of total billed charges,
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1296.537138,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3853.8539,9.170825,27238.33344,percent of total billed charges,
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3853.8539,9.170825,27238.33344,percent of total billed charges,
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4918.983888,9.170825,27238.33344,percent of total billed charges,
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7087.363309,9.170825,27238.33344,percent of total billed charges,
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7087.363309,9.170825,27238.33344,percent of total billed charges,
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7024.294836,9.170825,27238.33344,percent of total billed charges,
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7024.294836,9.170825,27238.33344,percent of total billed charges,
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,432.709381,9.170825,27238.33344,percent of total billed charges,
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1154.510838,9.170825,27238.33344,percent of total billed charges,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.714297,9.170825,27238.33344,percent of total billed charges,
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.714297,9.170825,27238.33344,percent of total billed charges,
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2907.806109,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2633.933354,9.170825,27238.33344,percent of total billed charges,
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.52232,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.52232,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.52232,9.170825,27238.33344,percent of total billed charges,
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,549.799588,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1359.722026,9.170825,27238.33344,percent of total billed charges,
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1359.722026,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,298.883871,9.170825,27238.33344,percent of total billed charges,
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,298.883871,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,931.648549,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,931.648549,9.170825,27238.33344,percent of total billed charges,
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2193.100793,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2193.100793,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2193.100793,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2193.100793,9.170825,27238.33344,percent of total billed charges,
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.541349,9.170825,27238.33344,percent of total billed charges,
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.541349,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.148443,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.148443,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.148443,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1318.95608,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1318.95608,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1318.95608,9.170825,27238.33344,percent of total billed charges,
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1318.95608,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2534.946973,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2534.946973,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2534.946973,9.170825,27238.33344,percent of total billed charges,
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2534.946973,9.170825,27238.33344,percent of total billed charges,
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2594.08838,9.170825,27238.33344,percent of total billed charges,
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2594.08838,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,209.70222,9.170825,27238.33344,percent of total billed charges,
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,712.850437,9.170825,27238.33344,percent of total billed charges,
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2352.848043,9.170825,27238.33344,percent of total billed charges,
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1611.750153,9.170825,27238.33344,percent of total billed charges,
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,105.500447,9.170825,27238.33344,percent of total billed charges,
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2259.524605,9.170825,27238.33344,percent of total billed charges,
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1813.768983,9.170825,27238.33344,percent of total billed charges,
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2157.418302,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1108.902028,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,431.941042,9.170825,27238.33344,percent of total billed charges,
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,647.466599,9.170825,27238.33344,percent of total billed charges,
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1773.145322,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7674.819269,9.170825,27238.33344,percent of total billed charges,
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2713.563801,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2559.538995,9.170825,27238.33344,percent of total billed charges,
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2476.912802,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,915.691933,9.170825,27238.33344,percent of total billed charges,
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1545.874785,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1196.735852,9.170825,27238.33344,percent of total billed charges,
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1570.029604,9.170825,27238.33344,percent of total billed charges,
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2300.148266,9.170825,27238.33344,percent of total billed charges,
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,9.170825,27238.33344,percent of total billed charges,
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,9.170825,27238.33344,percent of total billed charges,
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,9.170825,27238.33344,percent of total billed charges,
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,9.170825,27238.33344,percent of total billed charges,
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2198.041963,9.170825,27238.33344,percent of total billed charges,
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2198.041963,9.170825,27238.33344,percent of total billed charges,
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3068.968448,9.170825,27238.33344,percent of total billed charges,
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1548.071148,9.170825,27238.33344,percent of total billed charges,
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1548.071148,9.170825,27238.33344,percent of total billed charges,
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1548.071148,9.170825,27238.33344,percent of total billed charges,
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1688.604749,9.170825,27238.33344,percent of total billed charges,
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1586.498446,9.170825,27238.33344,percent of total billed charges,
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1586.498446,9.170825,27238.33344,percent of total billed charges,
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1114.611537,9.170825,27238.33344,percent of total billed charges,
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3650.10178,9.170825,27238.33344,percent of total billed charges,
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3260.885043,9.170825,27238.33344,percent of total billed charges,
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3650.10178,9.170825,27238.33344,percent of total billed charges,
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3650.10178,9.170825,27238.33344,percent of total billed charges,
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,634.459163,9.170825,27238.33344,percent of total billed charges,
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3669.465475,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,431.941042,9.170825,27238.33344,percent of total billed charges,
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,870.944594,9.170825,27238.33344,percent of total billed charges,
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3068.968448,9.170825,27238.33344,percent of total billed charges,
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,9.170825,27238.33344,percent of total billed charges,
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5487.158937,9.170825,27238.33344,percent of total billed charges,
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5487.158937,9.170825,27238.33344,percent of total billed charges,
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5931.416686,9.170825,27238.33344,percent of total billed charges,
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5487.158937,9.170825,27238.33344,percent of total billed charges,
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5775.324867,9.170825,27238.33344,percent of total billed charges,
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5775.324867,9.170825,27238.33344,percent of total billed charges,
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5775.324867,9.170825,27238.33344,percent of total billed charges,
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6065.89412,9.170825,27238.33344,percent of total billed charges,
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1554.65765,9.170825,27238.33344,percent of total billed charges,
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1148.581434,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1507.820015,9.170825,27238.33344,percent of total billed charges,
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.209319,9.170825,27238.33344,percent of total billed charges,
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.701098,9.170825,27238.33344,percent of total billed charges,
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1091.276797,9.170825,27238.33344,percent of total billed charges,
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,522.03073,9.170825,27238.33344,percent of total billed charges,
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1158.461187,9.170825,27238.33344,percent of total billed charges,
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,9.170825,27238.33344,percent of total billed charges,
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1113.913047,9.170825,27238.33344,percent of total billed charges,
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1113.913047,9.170825,27238.33344,percent of total billed charges,
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1427.29964,9.170825,27238.33344,percent of total billed charges,
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1427.29964,9.170825,27238.33344,percent of total billed charges,
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4581.866744,9.170825,27238.33344,percent of total billed charges,
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1877.996432,9.170825,27238.33344,percent of total billed charges,
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,228.238075,9.170825,27238.33344,percent of total billed charges,
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2338.575564,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3066.08653,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2711.64166,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1862.417518,9.170825,27238.33344,percent of total billed charges,
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2228.837611,9.170825,27238.33344,percent of total billed charges,
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.079647,9.170825,27238.33344,percent of total billed charges,
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1719.193437,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3249.070214,9.170825,27238.33344,percent of total billed charges,
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3249.070214,9.170825,27238.33344,percent of total billed charges,
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5589.392003,9.170825,27238.33344,percent of total billed charges,
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5589.392003,9.170825,27238.33344,percent of total billed charges,
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5589.392003,9.170825,27238.33344,percent of total billed charges,
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5343.249301,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4995.835897,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,264.466423,9.170825,27238.33344,percent of total billed charges,
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,264.166331,9.170825,27238.33344,percent of total billed charges,
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2536.201668,9.170825,27238.33344,percent of total billed charges,
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2536.201668,9.170825,27238.33344,percent of total billed charges,
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2536.201668,9.170825,27238.33344,percent of total billed charges,
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,734.845111,9.170825,27238.33344,percent of total billed charges,
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,734.845111,9.170825,27238.33344,percent of total billed charges,
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1592.153628,9.170825,27238.33344,percent of total billed charges,
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.567895,9.170825,27238.33344,percent of total billed charges,
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3530.033936,9.170825,27238.33344,percent of total billed charges,
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3530.033936,9.170825,27238.33344,percent of total billed charges,
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1882.937602,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,9.170825,27238.33344,percent of total billed charges,
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,9.170825,27238.33344,percent of total billed charges,
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,9.170825,27238.33344,percent of total billed charges,
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,9.170825,27238.33344,percent of total billed charges,
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2881.6593,9.170825,27238.33344,percent of total billed charges,
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1768.620659,9.170825,27238.33344,percent of total billed charges,
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2569.480836,9.170825,27238.33344,percent of total billed charges,
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2310.030606,9.170825,27238.33344,percent of total billed charges,
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6266.647907,9.170825,27238.33344,percent of total billed charges,
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3926.740038,9.170825,27238.33344,percent of total billed charges,
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1789.130395,9.170825,27238.33344,percent of total billed charges,
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2535.860184,9.170825,27238.33344,percent of total billed charges,
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1037.428392,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2535.860184,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2535.860184,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1037.428392,9.170825,27238.33344,percent of total billed charges,
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1521.719966,9.170825,27238.33344,percent of total billed charges,
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2662.654228,9.170825,27238.33344,percent of total billed charges,
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,309.213762,9.170825,27238.33344,percent of total billed charges,
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5514.534571,9.170825,27238.33344,percent of total billed charges,
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2749.419621,9.170825,27238.33344,percent of total billed charges,
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2749.419621,9.170825,27238.33344,percent of total billed charges,
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.574287,9.170825,27238.33344,percent of total billed charges,
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1556.854013,9.170825,27238.33344,percent of total billed charges,
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1114.391642,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1333.976202,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2593.49337,9.170825,27238.33344,percent of total billed charges,
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2714.394228,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2714.394228,9.170825,27238.33344,percent of total billed charges,
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2714.394228,9.170825,27238.33344,percent of total billed charges,
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2593.49337,9.170825,27238.33344,percent of total billed charges,
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1976.26104,9.170825,27238.33344,percent of total billed charges,
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2093.739297,9.170825,27238.33344,percent of total billed charges,
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,342.811131,9.170825,27238.33344,percent of total billed charges,
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2368.548546,9.170825,27238.33344,percent of total billed charges,
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3294.697133,9.170825,27238.33344,percent of total billed charges,
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3198.641823,9.170825,27238.33344,percent of total billed charges,
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2872.053769,9.170825,27238.33344,percent of total billed charges,
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3457.99116,9.170825,27238.33344,percent of total billed charges,
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3457.99116,9.170825,27238.33344,percent of total billed charges,
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1658.083323,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1882.937602,9.170825,27238.33344,percent of total billed charges,
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1959.792198,9.170825,27238.33344,percent of total billed charges,
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1114.391642,9.170825,27238.33344,percent of total billed charges,
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2830.654008,9.170825,27238.33344,percent of total billed charges,
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,716.319604,9.170825,27238.33344,percent of total billed charges,
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2830.654008,9.170825,27238.33344,percent of total billed charges,
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2728.338158,9.170825,27238.33344,percent of total billed charges,
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.52232,9.170825,27238.33344,percent of total billed charges,
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6243.59515,9.170825,27238.33344,percent of total billed charges,
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6243.59515,9.170825,27238.33344,percent of total billed charges,
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6243.59515,9.170825,27238.33344,percent of total billed charges,
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.57931,200.09685,4563.1488,percent of total billed charges,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5446.336077,399.86,21372.62592,percent of total billed charges,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2902.792503,399.86,21372.62592,percent of total billed charges,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3770.172211,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2414.408295,399.86,21372.62592,percent of total billed charges,
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7199.346778,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3580.940922,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3580.940922,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2414.408295,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4226.43364,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7199.346778,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4286.131252,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4286.131252,399.86,21372.62592,percent of total billed charges,
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,21372.62592,percent of total billed charges,
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2416.752117,399.86,21372.62592,percent of total billed charges,
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3223.616721,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2416.752117,399.86,21372.62592,percent of total billed charges,
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2442.87823,399.86,21372.62592,percent of total billed charges,
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3217.852885,399.86,21372.62592,percent of total billed charges,
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2708.759742,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3217.852885,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2776.479641,399.86,21372.62592,percent of total billed charges,
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6111.182142,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4511.717652,399.86,21372.62592,percent of total billed charges,
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,21372.62592,percent of total billed charges,
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3718.300274,399.86,21372.62592,percent of total billed charges,
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,21372.62592,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,399.86,21372.62592,percent of total billed charges,
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5278.240578,399.86,21372.62592,percent of total billed charges,
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5129.353554,399.86,21372.62592,percent of total billed charges,
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,399.86,21372.62592,percent of total billed charges,
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,399.86,21372.62592,percent of total billed charges,
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,21372.62592,percent of total billed charges,
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,46489.17504,percent of total billed charges,
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4178.405985,399.86,46489.17504,percent of total billed charges,
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2841.315035,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2705.282814,399.86,46489.17504,percent of total billed charges,
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3050.717163,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2207.549188,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2207.549188,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2207.549188,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3842.2124,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.628966,399.86,46489.17504,percent of total billed charges,
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3233.222252,399.86,46489.17504,percent of total billed charges,
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2302.344629,399.86,46489.17504,percent of total billed charges,
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2820.184419,399.86,46489.17504,percent of total billed charges,
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,399.86,46489.17504,percent of total billed charges,
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,46489.17504,percent of total billed charges,
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9605.531,399.86,46489.17504,percent of total billed charges,
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6860.788675,399.86,46489.17504,percent of total billed charges,
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10051.85318,399.86,46489.17504,percent of total billed charges,
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6860.788675,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2425.397871,399.86,46489.17504,percent of total billed charges,
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2425.397871,399.86,46489.17504,percent of total billed charges,
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,399.86,46489.17504,percent of total billed charges,
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,46489.17504,percent of total billed charges,
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3334.079034,399.86,46489.17504,percent of total billed charges,
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6142.738368,399.86,46489.17504,percent of total billed charges,
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15659.83019,399.86,46489.17504,percent of total billed charges,
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,46489.17504,percent of total billed charges,
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10453.9273,399.86,28973.58282,percent of total billed charges,
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,399.86,28973.58282,percent of total billed charges,
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,399.86,28973.58282,percent of total billed charges,
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,651.339338,399.86,28973.58282,percent of total billed charges,
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,399.86,28973.58282,percent of total billed charges,
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1607.292752,399.86,28973.58282,percent of total billed charges,
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.994531,399.86,28973.58282,percent of total billed charges,
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.994531,399.86,28973.58282,percent of total billed charges,
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,399.86,28973.58282,percent of total billed charges,
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,671.908575,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1148.581434,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.705589,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.705589,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1148.581434,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.705589,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,261.9915,4400.1792,percent of total billed charges,
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1148.581434,261.9915,4400.1792,percent of total billed charges,
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,938.625688,261.9915,4400.1792,percent of total billed charges,
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.711795,261.9915,4400.1792,percent of total billed charges,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,261.9915,4400.1792,percent of total billed charges,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,261.9915,4400.1792,percent of total billed charges,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,261.9915,4400.1792,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,301.9029,261.9915,4400.1792,percent of total billed charges,
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,301.9029,261.9915,4400.1792,percent of total billed charges,
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,301.9029,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1238.456401,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1454.74771,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1348.248681,261.9915,4400.1792,percent of total billed charges,
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1348.248681,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5283.04205,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5494.363732,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7336.258579,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3136.207165,150.646235,27674.62656,percent of total billed charges,
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3309.106723,150.646235,27674.62656,percent of total billed charges,
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,173.595461,150.646235,27674.62656,percent of total billed charges,
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8214.439012,150.646235,27674.62656,percent of total billed charges,
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8887.115926,150.646235,27674.62656,percent of total billed charges,
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8214.439012,150.646235,27674.62656,percent of total billed charges,
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3136.207165,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4009.348122,150.646235,27674.62656,percent of total billed charges,
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6519.346067,150.646235,27674.62656,percent of total billed charges,
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8140.406833,150.646235,27674.62656,percent of total billed charges,
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6908.655936,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7384.123253,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9322.169129,150.646235,27674.62656,percent of total billed charges,
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8370.163477,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6519.346067,150.646235,27674.62656,percent of total billed charges,
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8472.277541,150.646235,27674.62656,percent of total billed charges,
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,150.646235,27674.62656,percent of total billed charges,
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1449.258096,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6339.65046,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6920.786379,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6339.65046,150.646235,27674.62656,percent of total billed charges,
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,648.597118,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1795.103778,150.646235,27674.62656,percent of total billed charges,
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6973.615506,150.646235,27674.62656,percent of total billed charges,
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6973.615506,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7127.304002,150.646235,27674.62656,percent of total billed charges,
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6920.786379,150.646235,27674.62656,percent of total billed charges,
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7898.522333,150.646235,27674.62656,percent of total billed charges,
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4226.43364,399.86,21443.91168,percent of total billed charges,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6959.208503,399.86,21443.91168,percent of total billed charges,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7223.359312,399.86,21443.91168,percent of total billed charges,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7223.359312,399.86,21443.91168,percent of total billed charges,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6877.560196,399.86,21443.91168,percent of total billed charges,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6709.464697,399.86,21443.91168,percent of total billed charges,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,121.79596,99.62861,33156.48,percent of total billed charges,
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,121.79596,99.62861,33156.48,percent of total billed charges,
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.805886,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,99.62861,33156.48,percent of total billed charges,
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,99.62861,33156.48,percent of total billed charges,
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1339.465816,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1027.548639,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1027.548639,99.62861,33156.48,percent of total billed charges,
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,99.62861,33156.48,percent of total billed charges,
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1209.911443,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.06164,416.02,other,Non-Reimbursable Procedures
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.06164,416.02,other,Non-Reimbursable Procedures
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.06164,416.02,other,Non-Reimbursable Procedures
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.06164,416.02,other,Non-Reimbursable Procedures
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11806.93865,399.86,41625.59232,percent of total billed charges,
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,399.86,41625.59232,percent of total billed charges,
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8047.864669,399.86,41625.59232,percent of total billed charges,
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9892.29995,399.86,41625.59232,percent of total billed charges,
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10070.99956,399.86,41625.59232,percent of total billed charges,
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9892.29995,399.86,41625.59232,percent of total billed charges,
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,41625.59232,percent of total billed charges,
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,41625.59232,percent of total billed charges,
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14021.53741,399.86,41625.59232,percent of total billed charges,
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6627.81639,399.86,19675.9296,percent of total billed charges,
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6627.81639,399.86,19675.9296,percent of total billed charges,
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6627.81639,399.86,19675.9296,percent of total billed charges,
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,399.86,19675.9296,percent of total billed charges,
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,399.86,19675.9296,percent of total billed charges,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,399.86,19675.9296,percent of total billed charges,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,399.86,19675.9296,percent of total billed charges,
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2903.030507,399.86,19675.9296,percent of total billed charges,
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3842.931586,399.86,19675.9296,percent of total billed charges,
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5069.798227,399.86,19675.9296,percent of total billed charges,
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5069.798227,399.86,19675.9296,percent of total billed charges,
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2987.320141,399.86,19675.9296,percent of total billed charges,
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2987.320141,399.86,19675.9296,percent of total billed charges,
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2561.453375,399.86,19675.9296,percent of total billed charges,
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1427.29964,399.86,19675.9296,percent of total billed charges,
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,399.86,19675.9296,percent of total billed charges,
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5090.93143,399.86,19675.9296,percent of total billed charges,
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,19675.9296,percent of total billed charges,
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,19675.9296,percent of total billed charges,
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,19675.9296,percent of total billed charges,
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,19675.9296,percent of total billed charges,
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1427.29964,399.86,19675.9296,percent of total billed charges,
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,399.86,19675.9296,percent of total billed charges,
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,399.86,19675.9296,percent of total billed charges,
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,399.86,19675.9296,percent of total billed charges,
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,399.86,19675.9296,percent of total billed charges,
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,399.86,19675.9296,percent of total billed charges,
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5090.93143,399.86,19675.9296,percent of total billed charges,
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2881.6593,399.86,19675.9296,percent of total billed charges,
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3025.742265,399.86,19675.9296,percent of total billed charges,
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,46419.072,other,Non-Reimbursable Procedures
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,46419.072,other,Non-Reimbursable Procedures
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,46419.072,other,Non-Reimbursable Procedures
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,46419.072,other,Non-Reimbursable Procedures
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2621.49888,other,Non-Reimbursable Procedures
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2621.49888,other,Non-Reimbursable Procedures
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2621.49888,other,Non-Reimbursable Procedures
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2621.49888,other,Non-Reimbursable Procedures
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7592.15526,other,Non-Reimbursable Procedures
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7592.15526,other,Non-Reimbursable Procedures
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7592.15526,other,Non-Reimbursable Procedures
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6381.888,other,Non-Reimbursable Procedures
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11484.64243,399.86,42246.08608,percent of total billed charges,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4286.131252,399.86,12724.19328,percent of total billed charges,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6723.8717,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5147.604839,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5379.09736,399.86,24381.0432,percent of total billed charges,
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5643.250756,399.86,24381.0432,percent of total billed charges,
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5379.09736,399.86,24381.0432,percent of total billed charges,
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4706.71019,399.86,24381.0432,percent of total billed charges,
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,24381.0432,percent of total billed charges,
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,24381.0432,percent of total billed charges,
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7175.331657,399.86,24381.0432,percent of total billed charges,
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5255.185234,399.86,24381.0432,percent of total billed charges,
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8212.729005,399.86,24381.0432,percent of total billed charges,
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7396.25887,399.86,24381.0432,percent of total billed charges,
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6723.8717,399.86,24381.0432,percent of total billed charges,
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,24381.0432,percent of total billed charges,
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6723.8717,399.86,24381.0432,percent of total billed charges,
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6531.76108,399.86,24381.0432,percent of total billed charges,
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,24381.0432,percent of total billed charges,
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6307.951949,399.86,23086.3872,percent of total billed charges,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5283.04205,399.86,23086.3872,percent of total billed charges,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7776.62548,399.86,23086.3872,percent of total billed charges,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7776.62548,399.86,23086.3872,percent of total billed charges,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7336.258579,399.86,23086.3872,percent of total billed charges,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4030.481325,399.86,23086.3872,percent of total billed charges,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,622.543441,399.86,23086.3872,percent of total billed charges,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,622.543441,399.86,23086.3872,percent of total billed charges,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,622.543441,399.86,23086.3872,percent of total billed charges,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,622.543441,399.86,23086.3872,percent of total billed charges,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5249.423985,399.86,23086.3872,percent of total billed charges,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,196.236885,170.294475,582.5664,percent of total billed charges,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.890315,416.02,other,Non-Reimbursable Procedures
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.890315,416.02,other,Non-Reimbursable Procedures
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.890315,416.02,other,Non-Reimbursable Procedures
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.890315,416.02,other,Non-Reimbursable Procedures
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,536.530865,399.86,1487.02215,percent of total billed charges,
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1724.0184,other,Non-Reimbursable Procedures
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,267.439885,1479.062,other,Non-Reimbursable Procedures
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2573.3136,other,Non-Reimbursable Procedures
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,77.228,836,other,Non-Reimbursable Procedures
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.71,921.95328,other,Non-Reimbursable Procedures
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-51,NDC,outpatient,1,UN,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.211885,1.69273,416.02,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-00,NDC,outpatient,1,UN,7.54,5.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.950598,1.69273,416.02,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-60,NDC,outpatient,1,UN,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.211885,1.69273,416.02,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-10,NDC,outpatient,1,UN,7.54,5.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.950598,1.69273,416.02,percent of total billed charges,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-55,NDC,outpatient,1,UN,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.211885,1.69273,416.02,percent of total billed charges,
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,281.887281,1.4,836.83584,percent of total billed charges,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.39,416.02,other,Non-Reimbursable Procedures
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,,,,3.39,416.02,other,Non-Reimbursable Procedures
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.39,416.02,other,Non-Reimbursable Procedures
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,,,,3.39,416.02,other,Non-Reimbursable Procedures
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.31,416.02,other,Non-Reimbursable Procedures
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.31,416.02,other,Non-Reimbursable Procedures
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.31,416.02,other,Non-Reimbursable Procedures
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.36,1148.18304,other,Non-Reimbursable Procedures
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.36,1148.18304,other,Non-Reimbursable Procedures
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5136.79872,other,Non-Reimbursable Procedures
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5136.79872,other,Non-Reimbursable Procedures
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5136.79872,other,Non-Reimbursable Procedures
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,182.24,5164.04736,other,Non-Reimbursable Procedures
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,182.24,5164.04736,other,Non-Reimbursable Procedures
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,182.24,5164.04736,other,Non-Reimbursable Procedures
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,41430.25152,other,Non-Reimbursable Procedures
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,41430.25152,other,Non-Reimbursable Procedures
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,41430.25152,other,Non-Reimbursable Procedures
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,41430.25152,other,Non-Reimbursable Procedures
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,177.26,5164.08576,other,Non-Reimbursable Procedures
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,177.26,5164.08576,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.39,18739.8144,other,Non-Reimbursable Procedures
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.39,18739.8144,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.39,18739.8144,other,Non-Reimbursable Procedures
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.39,18739.8144,other,Non-Reimbursable Procedures
SARILUMAB 200 MG/1.14ML SC SOAJ,RX-143091,CDM,C9399,HCPCS,636,RC,00024-5922-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1504.006777,399.86,4927.700596,percent of total billed charges,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.2,1865.41824,other,Non-Reimbursable Procedures
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.2,1865.41824,other,Non-Reimbursable Procedures
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8429.4808,399.86,25024.512,percent of total billed charges,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,26025.216,other,Non-Reimbursable Procedures
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26793.51305,percent of total billed charges,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26025.216,percent of total billed charges,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26025.216,percent of total billed charges,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26793.51305,percent of total billed charges,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26025.216,percent of total billed charges,
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.9291,19.95,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.6205,19.95,416.02,percent of total billed charges,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.9291,19.95,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.6205,19.95,416.02,percent of total billed charges,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.9291,19.95,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.6205,19.95,416.02,percent of total billed charges,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.9449,185.6615,1592,percent of total billed charges,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,445.4814,386.589,2141,percent of total billed charges,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.349,1592,other,Non-Reimbursable Procedures
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,25.3685,416.02,other,Non-Reimbursable Procedures
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.8201,12.01,416.02,percent of total billed charges,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.1287,22.6745,6652,percent of total billed charges,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.1287,22.6745,6652,percent of total billed charges,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,373.0454,104.83,6652,percent of total billed charges,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7964.16,other,Non-Reimbursable Procedures
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7964.16,other,Non-Reimbursable Procedures
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7964.16,other,Non-Reimbursable Procedures
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,53.88,416.02,other,Non-Reimbursable Procedures
HC Inter Devc Remote 30d,PX-48000092,CDM,G2066,HCPCS,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,989.157559,43.27,2936.50176,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.925821,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.925821,0.04,416.02,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.045363,0.57,416.02,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.045363,0.57,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.951518,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.791124,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.791124,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.30243,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.967289,0.02,416.02,percent of total billed charges,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.30243,0.02,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2397.274594,336.23,7116.76416,percent of total billed charges,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2397.274594,336.23,7116.76416,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.102733,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.102733,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.102733,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.756421,0.4,631.24992,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.384564,0.4,631.24992,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,212.635878,0.4,631.24992,percent of total billed charges,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.384716,0.4,631.24992,percent of total billed charges,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.384716,0.4,631.24992,percent of total billed charges,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.553225,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.553225,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,323.693201,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.129856,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,323.693201,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.129856,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.553225,0.73,960.94464,percent of total billed charges,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.553225,0.73,960.94464,percent of total billed charges,
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.676473,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.893359,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.893359,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.99475,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.893359,0.73,960.94464,percent of total billed charges,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.893359,0.73,960.94464,percent of total billed charges,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.308026,1.61,416.02,percent of total billed charges,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.308026,1.61,416.02,percent of total billed charges,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5322.768022,215.38,15801.64608,percent of total billed charges,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,760.26756,215.38,15801.64608,percent of total billed charges,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,688.615421,194.92,2044.28544,percent of total billed charges,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,428.037259,5.51,1270.70976,percent of total billed charges,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,378.42636,4.88,1606.272,percent of total billed charges,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,378.42636,4.88,1606.272,percent of total billed charges,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,541.07105,4.88,1606.272,percent of total billed charges,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,146.041324,2.98,4260,percent of total billed charges,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,146.041324,2.98,4260,percent of total billed charges,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.55312,0.77,416.02,percent of total billed charges,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.55312,0.77,416.02,percent of total billed charges,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.970298,4.51,416.02,percent of total billed charges,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.796222,4.51,416.02,percent of total billed charges,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.970298,4.51,416.02,percent of total billed charges,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.796222,4.51,416.02,percent of total billed charges,
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.647539,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.434367,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.281485,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.339741,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.281485,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.926146,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.926146,0.46,416.02,percent of total billed charges,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.434367,0.46,416.02,percent of total billed charges,
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.155414,34.84689,416.02,percent of total billed charges,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.691138,11.13,416.02,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,328.202342,23.33,974.33088,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.099365,23.33,974.33088,percent of total billed charges,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.747394,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.109823,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.229994,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.229994,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.109823,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.747394,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.278898,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.49245,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.425859,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.788537,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.701001,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.425859,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.788537,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.109823,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.229994,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.229994,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.109823,0.78,416.02,percent of total billed charges,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,0.78,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.759257,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.433869,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.433869,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.256037,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.691151,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.45857,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.844531,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.45857,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.362353,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.69232,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.669535,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.574487,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.69232,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.574487,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.29534,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.29534,1.600685,416.02,percent of total billed charges,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.669535,1.600685,416.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.70585,0.82,416.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.839454,0.82,416.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.658018,0.82,416.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.17492,0.82,416.02,percent of total billed charges,
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.057606,0.46,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.148379,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.148379,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.808064,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.748563,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.808064,2.732165,416.02,percent of total billed charges,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.748563,2.732165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.309693,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.138031,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.59593,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.309693,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.385214,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.59593,1.834165,416.02,percent of total billed charges,
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.931244,1.834165,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.620901,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.531103,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.531103,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,63.239215,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.531103,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.620901,1.97,416.02,percent of total billed charges,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.531103,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,63.239215,1.97,416.02,percent of total billed charges,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.051664,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.995497,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.995497,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.957612,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.957612,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.656946,0.09,416.02,percent of total billed charges,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.656946,0.09,416.02,percent of total billed charges,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,205.493171,174.58,1359.95136,percent of total billed charges,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,387.498969,174.58,1359.95136,percent of total billed charges,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,458.098199,174.58,1359.95136,percent of total billed charges,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.545747,40.38,416.02,percent of total billed charges,
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,453.622689,50.93,4488.66816,percent of total billed charges,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1512.003194,50.93,4488.66816,percent of total billed charges,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.637744,9.23144,416.02,percent of total billed charges,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.637744,9.23144,416.02,percent of total billed charges,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.417068,9.23144,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.494387,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.282751,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.494387,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.640926,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.282751,16.21,416.02,percent of total billed charges,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.640926,16.21,416.02,percent of total billed charges,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.075516,15.67,697.86624,percent of total billed charges,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.075516,15.67,697.86624,percent of total billed charges,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,154.076546,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,154.076546,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,294.905065,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,294.905065,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,546.8918,20.17,1623.552,percent of total billed charges,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,546.8918,20.17,1623.552,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.189737,0.17,416.02,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.189737,0.17,416.02,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.010715,0.17,416.02,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.780493,0.17,416.02,percent of total billed charges,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.780493,0.17,416.02,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,452.683608,6.15,1343.87712,percent of total billed charges,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.752492,4.03,416.02,percent of total billed charges,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.752492,4.03,416.02,percent of total billed charges,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.745478,4.06,416.02,percent of total billed charges,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.745478,4.06,416.02,percent of total billed charges,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4259.710221,60.43,12645.75744,percent of total billed charges,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4259.710221,60.43,12645.75744,percent of total billed charges,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.452898,0.04,416.02,percent of total billed charges,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.452898,0.04,416.02,percent of total billed charges,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.670206,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.670206,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.809406,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.809406,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,9.670206,0.08,416.02,percent of total billed charges,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,9.670206,0.08,416.02,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,726.059659,399.86,2155.44576,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,567.383427,399.86,2155.44576,percent of total billed charges,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.390139,2.68951,416.02,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.608464,2.68951,416.02,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.099226,2.68951,416.02,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.296302,4.2921885,416.02,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.912928,4.2921885,416.02,percent of total billed charges,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.912928,4.2921885,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.067933,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.806895,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.023034,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.676376,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.023034,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.067933,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.874157,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.676376,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.475759,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.192358,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.475759,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.514564,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.628143,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.607696,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.026541,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.390139,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.390139,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.31136,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.31136,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.42285,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.42285,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.01,416.02,percent of total billed charges,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.01,416.02,percent of total billed charges,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.267132,0.01,416.02,percent of total billed charges,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.267132,0.01,416.02,percent of total billed charges,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.230665,3.08,416.02,percent of total billed charges,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.230665,3.08,416.02,percent of total billed charges,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.917638,1.22,416.02,percent of total billed charges,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.056838,1.22,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.513395,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.58083,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.58083,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.107236,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.848038,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.848038,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.148379,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.148379,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.513395,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.513395,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.51123,0.74534,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.063928,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.1044,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.648839,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.1044,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.59685,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.335314,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.59685,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.036889,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.036889,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.658191,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.59685,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.59685,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.036889,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.875997,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.1044,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.1044,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.648839,1.22,416.02,percent of total billed charges,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.063928,1.22,416.02,percent of total billed charges,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,38.114271,3.679555,416.02,percent of total billed charges,
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.936418,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.586004,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.240093,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.223748,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.848958,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.240093,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.586004,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.848958,3.679555,416.02,percent of total billed charges,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.223748,3.679555,416.02,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,168.755184,7.54,500.98176,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.353001,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.353001,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.654013,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.654013,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.385214,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.881918,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.842864,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.336061,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.359344,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.359344,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.881918,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.654013,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.353001,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.654013,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.353001,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.795378,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.795378,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.385214,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.359344,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.336061,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.359344,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.881918,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.881918,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.842864,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.117584,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.897689,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.117584,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.897689,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.637571,0.44,416.02,percent of total billed charges,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.637571,0.44,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.23375,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.48352,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.23375,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.598268,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.598268,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.48352,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.23375,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.23375,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.598268,1.88,416.02,percent of total billed charges,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.598268,1.88,416.02,percent of total billed charges,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.173025,6.96,416.02,percent of total billed charges,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.232104,6.96,416.02,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.920225,1.65,416.02,percent of total billed charges,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.662246,3.89,619.45344,percent of total billed charges,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.662246,3.89,619.45344,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.662246,3.89,619.45344,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.662246,3.89,619.45344,percent of total billed charges,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.574487,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.084624,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.574487,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,1.66,416.02,percent of total billed charges,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.588169,1.66,416.02,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.584112,92.48,1248.58368,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.584112,92.48,1248.58368,percent of total billed charges,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.698414,10.15189,416.02,percent of total billed charges,
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.243165,10.15189,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.619213,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.619213,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.487449,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.487449,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.745651,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.745651,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,12.606451,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,12.606451,1.61,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.996417,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.996417,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.860475,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.860475,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.721275,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.721275,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.860475,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.860475,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.721275,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.721275,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,5.87249,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,5.87249,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.01169,2.59,416.02,percent of total billed charges,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.01169,2.59,416.02,percent of total billed charges,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.617546,5.74271,416.02,percent of total billed charges,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.362104,5.74271,416.02,percent of total billed charges,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.362104,5.74271,416.02,percent of total billed charges,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.93316,1.86,416.02,percent of total billed charges,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.93316,1.86,416.02,percent of total billed charges,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.04649,1.86,416.02,percent of total billed charges,
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.988158,10.40333,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.551951,3.01,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.551951,3.01,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.872739,3.01,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.051242,3.01,416.02,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.872739,3.01,416.02,percent of total billed charges,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.148974,16.61749,416.02,percent of total billed charges,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.327443,16.61749,416.02,percent of total billed charges,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.327443,16.61749,416.02,percent of total billed charges,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.017286,0.04,416.02,percent of total billed charges,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,659.747088,14.7,4668.927562,percent of total billed charges,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.12805,0.03,416.02,percent of total billed charges,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.151333,0.03,416.02,percent of total billed charges,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.898533,0.03,416.02,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.222123,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,113.447711,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.782755,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,109.308511,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,88.643555,1.35,1059.84,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,82.082923,1.35,1059.84,percent of total billed charges,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,357.006,1.35,1059.84,percent of total billed charges,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,58.505005,1.35,1059.84,percent of total billed charges,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,343.765734,1.35,1059.84,percent of total billed charges,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,161.154578,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,161.154578,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,73.318167,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,73.318167,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,118.181921,6.88,478.41792,percent of total billed charges,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,118.181921,6.88,478.41792,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,88.643555,0.46,416.02,percent of total billed charges,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.782755,0.46,416.02,percent of total billed charges,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.762806,1.63,416.02,percent of total billed charges,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.988158,6.78,416.02,percent of total billed charges,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.988158,6.78,416.02,percent of total billed charges,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2292.371744,24.19,6805.34016,percent of total billed charges,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.776497,24.19,6805.34016,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1030,HCPCS,636,RC,00009-3073-03,NDC,outpatient,1,ML,22.62,15.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.851794,5.07819,416.02,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-01,NDC,outpatient,1,ML,25.95,18.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.713265,5.82353,416.02,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-05,NDC,outpatient,1,ML,25.94,18.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.710678,5.82353,416.02,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,00009-3475-03,NDC,outpatient,1,ML,34.96,24.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.044152,5.82353,416.02,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.844704,0.03,416.02,percent of total billed charges,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.037387,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.954603,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.954603,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.580657,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.808313,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,0.11,416.02,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.580657,0.11,416.02,percent of total billed charges,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.434063,40.295505,416.02,percent of total billed charges,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.434063,40.295505,416.02,percent of total billed charges,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.164939,40.295505,416.02,percent of total billed charges,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.858808,10.29108,416.02,percent of total billed charges,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.538041,10.29108,416.02,percent of total billed charges,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.291778,10.29108,416.02,percent of total billed charges,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.782194,3.28219,416.02,percent of total billed charges,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.782194,3.28219,416.02,percent of total billed charges,
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,116.257193,3.28219,416.02,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3155.57086,399.86,9367.9104,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.505634,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.703415,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.703415,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.76809,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.76809,0.44,416.02,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.505634,0.44,416.02,percent of total billed charges,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-03,NDC,outpatient,10,ML,44.91,31.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.618217,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00409-2634-25,NDC,outpatient,10,ML,71.61,50.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.525507,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-01,NDC,outpatient,10,ML,44.91,31.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.618217,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-03,NDC,outpatient,1,ML,11.43,8.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.956941,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-31,NDC,outpatient,1,ML,11.43,8.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.956941,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-11,NDC,outpatient,1,ML,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.034551,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-01,NDC,outpatient,1,ML,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.034551,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-96,NDC,outpatient,0.5,ML,12.4,8.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.20788,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-06,NDC,outpatient,0.5,ML,12.4,8.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.20788,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-01,NDC,outpatient,1,ML,11.17,7.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.889679,2.507665,416.02,percent of total billed charges,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-25,NDC,outpatient,1,ML,11.17,7.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.889679,2.507665,416.02,percent of total billed charges,
CONC DILAUDID 10 MG/ML PCA,RX-4080160,CDM,J1170,HCPCS,636,RC,99999-0000-95,NDC,outpatient,50,ML,267.65,187.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.241055,2.507665,416.02,percent of total billed charges,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,148.923242,87.49,442.10688,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.74534,416.02,percent of total billed charges,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.74534,416.02,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.11452,31.3402,416.02,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.254685,399.86,1422.7584,percent of total billed charges,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.250863,9.763505,945.2928,percent of total billed charges,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,224.993977,9.763505,945.2928,percent of total billed charges,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,318.420895,9.763505,945.2928,percent of total billed charges,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.152953,9.763505,945.2928,percent of total billed charges,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.606873,3.78,416.02,percent of total billed charges,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.606873,3.78,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.638664,4.15774,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.895275,4.15774,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.817838,4.15774,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.817838,4.15774,416.02,percent of total billed charges,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.638664,4.15774,416.02,percent of total billed charges,
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.335563,4.15774,416.02,percent of total billed charges,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.791124,4.15774,416.02,percent of total billed charges,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.137533,4.15774,416.02,percent of total billed charges,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.791124,4.15774,416.02,percent of total billed charges,
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.759333,0.7,416.02,percent of total billed charges,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.487449,0.7,416.02,percent of total billed charges,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.061763,0.7,416.02,percent of total billed charges,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.061763,0.7,416.02,percent of total billed charges,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.404492,0.7,416.02,percent of total billed charges,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.404492,0.7,416.02,percent of total billed charges,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.670704,0.7,416.02,percent of total billed charges,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4657.495102,224.63,13826.65728,percent of total billed charges,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.404285,15.86,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.103003,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.898879,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.061438,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.411105,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.061438,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.103003,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.411105,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.703263,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.703263,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.891616,10.42,416.02,percent of total billed charges,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.898879,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.103003,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.898879,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.061438,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.411105,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.703263,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.103003,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.411105,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.703263,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.891616,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.061438,10.42,416.02,percent of total billed charges,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.898879,10.42,416.02,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.060961,52.988735,416.02,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.060961,52.988735,416.02,percent of total billed charges,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,391.506232,339.74932,1162.26048,percent of total billed charges,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,641.133623,1.1,1903.32672,percent of total billed charges,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.320961,2.61,416.02,percent of total billed charges,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.194198,2.61,416.02,percent of total billed charges,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.194198,2.61,416.02,percent of total billed charges,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.204546,2.61,416.02,percent of total billed charges,
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.069102,2.61,416.02,percent of total billed charges,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,521.226173,7.3781655,1590,percent of total billed charges,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,434.84883,7.3781655,1590,percent of total billed charges,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,355.955678,0.14,1056.72192,percent of total billed charges,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,355.955678,0.14,1056.72192,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,696.518706,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1393.037412,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2786.074824,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,696.518706,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2786.074824,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,696.518706,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,696.518706,47.99,8270.99136,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,109.37836,48.47,416.02,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,109.37836,48.47,416.02,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2172.883388,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,543.220847,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,543.220847,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.441694,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,543.220847,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,543.220847,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.441694,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2172.883388,48.81,6450.61632,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.75515,77.77,1531.4,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.394076,77.77,1531.4,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,298.788152,77.77,1531.4,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,487.527911,44.12,1447.31904,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,487.527911,44.12,1447.31904,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1410.603142,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2115.904713,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1410.603142,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2115.904713,46.03,6281.46432,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.910569,36.41,416.02,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1099.57848,48.52,3264.3072,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,549.78924,48.52,3264.3072,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1099.57848,48.52,3264.3072,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,549.78924,48.52,3264.3072,percent of total billed charges,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,549.78924,48.52,3264.3072,percent of total billed charges,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.532175,1.23924,416.02,percent of total billed charges,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.4675,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.555956,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.555956,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.547794,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.246685,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.246685,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.547794,1.23924,416.02,percent of total billed charges,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,1.23924,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.955772,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.431531,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.431531,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.130519,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.472003,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.472003,0.51,416.02,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.130519,0.51,416.02,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.450125,90.641875,579.456,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.450125,90.641875,579.456,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.18915,90.641875,579.456,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.450125,90.641875,579.456,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,157.964807,101.41,468.94848,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,157.964807,101.41,468.94848,percent of total billed charges,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,157.959633,101.41,468.94848,percent of total billed charges,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.964702,0.28,416.02,percent of total billed charges,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.964702,0.28,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.867814,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.046068,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.046068,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.867814,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.972712,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.972712,0.74534,416.02,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.02,416.02,other,Non-Reimbursable Procedures
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.02,416.02,other,Non-Reimbursable Procedures
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.303848,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.348747,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.840277,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.990821,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.136613,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.63966,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.080868,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.137782,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.840277,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.990821,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.659436,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.659436,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.391557,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.080868,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.136613,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.63966,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.631899,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.631899,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.391557,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.137782,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.759582,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.759582,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.032213,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.032213,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.645332,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.645332,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.861471,0.22,416.02,percent of total billed charges,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.861471,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.515408,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.515408,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.969053,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.067283,0.22,416.02,percent of total billed charges,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.652941,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.74406,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.6914,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.463495,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.913882,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.172831,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.86448,0.22,416.02,percent of total billed charges,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.054251,0.22,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.181761,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.90729,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.360935,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.81458,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.268225,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.72187,0.57,416.02,percent of total billed charges,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.903631,0.57,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.806418,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.139124,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.139124,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.806418,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.809655,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.809655,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.806418,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.806418,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.368025,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.4327,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.368025,0.92,416.02,percent of total billed charges,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.4327,0.92,416.02,percent of total billed charges,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,384.047911,333.276985,1140.11904,percent of total billed charges,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,384.047911,333.276985,1140.11904,percent of total billed charges,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,39.68458,13.56878,416.02,percent of total billed charges,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.86069,13.56878,416.02,percent of total billed charges,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.635828,13.56878,416.02,percent of total billed charges,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.650603,13.56878,416.02,percent of total billed charges,
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.48866,27.14,416.02,percent of total billed charges,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,98.373262,85.36837,416.02,percent of total billed charges,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,808.419391,32.22,2399.94624,percent of total billed charges,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.754678,17.18,416.02,percent of total billed charges,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.754678,17.18,416.02,percent of total billed charges,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.159191,0.21,416.02,percent of total billed charges,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.516923,0.21,416.02,percent of total billed charges,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.159191,0.21,416.02,percent of total billed charges,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.075964,0.21,416.02,percent of total billed charges,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.105071,3.83,416.02,percent of total billed charges,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.105071,3.83,416.02,percent of total billed charges,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,1.834165,416.02,percent of total billed charges,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,1.834165,416.02,percent of total billed charges,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,82.88748,0.19,416.02,percent of total billed charges,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,106.201524,0.19,416.02,percent of total billed charges,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,110.340724,0.19,416.02,percent of total billed charges,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.02668,0.19,416.02,percent of total billed charges,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.428944,0.19,416.02,percent of total billed charges,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.428944,0.19,416.02,percent of total billed charges,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.687893,0.19,416.02,percent of total billed charges,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.491939,0.36,416.02,percent of total billed charges,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,107.352739,0.36,416.02,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,482.480674,114.43,1432.33536,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,482.480674,114.43,1432.33536,percent of total billed charges,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,406.759184,1,1207.54176,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.268301,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,1.329718,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,2.129101,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.468918,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.268301,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,2.129101,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.00184,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,2.527499,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,1.86264,0.02,416.02,percent of total billed charges,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.666699,0.02,416.02,percent of total billed charges,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.269719,0.02,416.02,percent of total billed charges,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.269719,0.02,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.527499,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.24176,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.767841,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.923559,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.767841,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.527499,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.55,416.02,percent of total billed charges,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.24176,0.55,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.140618,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.13211,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.581826,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.183179,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.183179,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.547199,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.13211,0.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.289495,1.24,416.02,percent of total billed charges,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.881669,1.24,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.079948,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.235168,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.989154,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.989154,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.676127,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.079948,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.235168,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.197532,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.197532,0.62,416.02,percent of total billed charges,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.676127,0.62,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.390388,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.390388,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.86264,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.86264,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.277978,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.946842,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.980473,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.980473,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.875575,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.399567,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.154971,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.277978,0.4,416.02,percent of total billed charges,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.946842,0.4,416.02,percent of total billed charges,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1231.07569,399.86,10964.15232,percent of total billed charges,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3693.263288,399.86,10964.15232,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.572322,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.458494,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.544363,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.544363,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.675055,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.675055,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.458494,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.162905,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.572322,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.602868,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.602868,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.537522,0.06,416.02,percent of total billed charges,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.537522,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.650506,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.650506,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.311609,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.76809,0.06,416.02,percent of total billed charges,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.76809,0.06,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.534762,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.666699,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.463495,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.666699,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.463495,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.33014,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.728538,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.33014,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.534762,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.865898,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.79672,0.92,416.02,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.201039,0.92,416.02,percent of total billed charges,
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2001,HCPCS,636,RC,00338-0409-03,NDC,outpatient,500,ML,42.7,29.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.02,416.02,other,Non-Reimbursable Procedures
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.898457,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.809406,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.898457,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,3.08,416.02,percent of total billed charges,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.898457,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.898457,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.809406,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,3.08,416.02,percent of total billed charges,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,3.08,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.154722,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.303848,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.277978,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.277978,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.154722,0.85,416.02,percent of total billed charges,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.303848,0.85,416.02,percent of total billed charges,
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.748833,0.85,416.02,percent of total billed charges,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.659436,2.30786,416.02,percent of total billed charges,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.659436,2.30786,416.02,percent of total billed charges,
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.503891,2.386435,416.02,percent of total billed charges,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.749981,2.386435,416.02,percent of total billed charges,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.749981,2.386435,416.02,percent of total billed charges,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.866396,2.386435,416.02,percent of total billed charges,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.866396,2.386435,416.02,percent of total billed charges,
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2107.165827,29.75,6255.52128,percent of total billed charges,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,0.35,416.02,percent of total billed charges,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,0.35,416.02,percent of total billed charges,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.927315,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.179174,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.663365,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.887265,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.887265,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.663365,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.179174,0.35,416.02,percent of total billed charges,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.457401,0.35,416.02,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.498468,15.18518,416.02,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.073453,15.18518,416.02,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.073453,15.18518,416.02,percent of total billed charges,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.498468,15.18518,416.02,percent of total billed charges,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.519518,1.07677,506.21952,percent of total billed charges,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.487719,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.454628,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.487719,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,198.919604,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.206483,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.972851,0.29,590.53056,percent of total billed charges,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.972851,0.29,590.53056,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.572896,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.572896,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.479515,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.479515,0.13,416.02,percent of total billed charges,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.174692,0.13,416.02,percent of total billed charges,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.588764,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.021865,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.087709,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.021865,0.13,416.02,percent of total billed charges,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.087709,0.13,416.02,percent of total billed charges,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.025967,0.18,416.02,percent of total billed charges,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.025967,0.18,416.02,percent of total billed charges,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,1.41,416.02,percent of total billed charges,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,1.41,416.02,percent of total billed charges,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.004849,1.41,416.02,percent of total billed charges,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.255615,1.41,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.338648,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.706002,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.706002,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.338648,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.762916,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.762916,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.568891,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.635406,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.568891,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.93159,2.02948,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.201537,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.201537,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.421432,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.421432,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.139449,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.092883,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.139449,1.816205,416.02,percent of total billed charges,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.241857,10.46,1022.48448,percent of total billed charges,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.241857,10.46,1022.48448,percent of total billed charges,
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,179.912915,10.46,1022.48448,percent of total billed charges,
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,344.422832,10.46,1022.48448,percent of total billed charges,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.602273,2.72,416.02,percent of total billed charges,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.602273,2.72,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.228251,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,12.089051,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.500135,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,10.360935,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.077036,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.768263,1.3,416.02,percent of total billed charges,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,10.937836,1.3,416.02,percent of total billed charges,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.29718,1.3,416.02,percent of total billed charges,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.29718,1.3,416.02,percent of total billed charges,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.886096,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.339492,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.49245,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.994328,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.49245,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.994328,3.03075,416.02,percent of total billed charges,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.339492,3.03075,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.547946,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.547946,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.073356,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.083704,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.073356,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.083704,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.511479,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.034724,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.034724,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.842117,0.86,416.02,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.842117,0.86,416.02,percent of total billed charges,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.878163,38.29,2935.67232,percent of total billed charges,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,494.440375,38.29,2935.67232,percent of total billed charges,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.878163,38.29,2935.67232,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.153228,0.92,416.02,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.49916,0.92,416.02,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.921242,0.92,416.02,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.153228,0.92,416.02,percent of total billed charges,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.020793,0.92,416.02,percent of total billed charges,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.974801,4.317135,416.02,percent of total billed charges,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.974801,4.317135,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.159647,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.539936,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.413173,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.192358,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.558543,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.558543,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.09639,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.09639,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.678963,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.192358,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.678963,0.01,416.02,percent of total billed charges,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.884754,0.01,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.401082,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.240266,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.401082,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.240266,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.412599,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.977561,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.977561,0.03,416.02,percent of total billed charges,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.412599,0.03,416.02,percent of total billed charges,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.637744,0.54,416.02,percent of total billed charges,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.637744,0.54,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.575483,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.68247,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.933907,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.933907,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.575483,0.09,416.02,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.008854,8.263845,416.02,percent of total billed charges,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.522747,8.263845,416.02,percent of total billed charges,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.49337,0.62,416.02,percent of total billed charges,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.445884,0.62,416.02,percent of total billed charges,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.531677,0.5,416.02,percent of total billed charges,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15384.26036,399.86,45671.09376,percent of total billed charges,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.401829,1.01,416.02,percent of total billed charges,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.638491,1.01,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.767841,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.903285,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.233252,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.788537,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.903285,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.788537,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.532673,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.339817,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.532673,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.501131,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.568642,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.568642,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.054078,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.676127,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.266212,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.054078,1.1,416.02,percent of total billed charges,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.501131,1.1,416.02,percent of total billed charges,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.004925,1.739875,416.02,percent of total billed charges,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.004925,1.739875,416.02,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.323569,13.89655,416.02,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.323569,13.89655,416.02,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.01353,13.89655,416.02,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.01353,13.89655,416.02,percent of total billed charges,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.919554,0.74534,416.02,percent of total billed charges,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.77453,5.42,416.02,percent of total billed charges,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.77453,5.42,416.02,percent of total billed charges,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,138.262215,1.62,422.7456,percent of total billed charges,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,138.262215,1.62,422.7456,percent of total billed charges,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,142.401415,1.62,422.7456,percent of total billed charges,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,142.401415,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,45.487221,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.147134,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.675878,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,45.487221,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.675878,1.62,422.7456,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.147134,1.62,422.7456,percent of total billed charges,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.075694,4.40469,416.02,percent of total billed charges,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.508643,4.586535,416.02,percent of total billed charges,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.285241,4.586535,416.02,percent of total billed charges,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.320041,5.484535,1082.90304,percent of total billed charges,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.320041,5.484535,1082.90304,percent of total billed charges,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,364.774761,5.484535,1082.90304,percent of total billed charges,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,364.774761,5.484535,1082.90304,percent of total billed charges,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.540206,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,126.63365,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,38.924002,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.424939,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.943757,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.424939,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.511479,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.892688,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.892688,0.87,416.02,percent of total billed charges,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.511479,0.87,416.02,percent of total billed charges,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.049326,0.43,416.02,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.049326,0.43,416.02,percent of total billed charges,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.594934,0.95,416.02,percent of total billed charges,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.826194,0.95,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.457401,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.457401,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.92943,416.02,percent of total billed charges,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.348996,0.92943,416.02,percent of total billed charges,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,495.705418,7.136465,1471.59552,percent of total billed charges,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,495.705418,7.136465,1471.59552,percent of total billed charges,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,795.016144,357.36,11800.75008,percent of total billed charges,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3975.070372,357.36,11800.75008,percent of total billed charges,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,153.551385,2.88,455.8464,percent of total billed charges,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.944677,2.88,455.8464,percent of total billed charges,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.977139,2.88,455.8464,percent of total billed charges,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1012.277578,33.71,3005.13792,percent of total billed charges,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1012.277578,33.71,3005.13792,percent of total billed charges,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,596.0448,10.7,2359.38048,percent of total billed charges,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,794.754857,10.7,2359.38048,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.318872,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.405585,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.228327,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.228327,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.405585,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.318872,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.069351,0.06,416.02,percent of total billed charges,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.069351,0.06,416.02,percent of total billed charges,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,893.943024,95.47,5307.61728,percent of total billed charges,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1787.865352,95.47,5307.61728,percent of total billed charges,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1072.032104,139.22,12730.14528,percent of total billed charges,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4288.136177,139.22,12730.14528,percent of total billed charges,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.269221,2.12,416.02,percent of total billed charges,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.269221,2.12,416.02,percent of total billed charges,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.956616,2.12,416.02,percent of total billed charges,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.956616,2.12,416.02,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-28,NDC,outpatient,1,UN,20.03,14.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.181761,4.24,416.02,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-30,NDC,outpatient,1,UN,20.03,14.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.181761,4.24,416.02,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2930,HCPCS,636,RC,00009-0698-01,NDC,outpatient,1,UN,79.04,55.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.447648,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-22,NDC,outpatient,1,UN,31.87,22.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.244769,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-25,NDC,outpatient,1,UN,31.87,22.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.244769,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2930,HCPCS,636,RC,00009-0850-01,NDC,outpatient,1,UN,735.77,515.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.343699,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2930,HCPCS,636,RC,00009-0758-01,NDC,outpatient,1,UN,87,60.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.5069,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ ACT-O-VIAL,RX-4081056,CDM,J2930,HCPCS,636,RC,00009-0018-20,NDC,outpatient,1,UN,235.14,164.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.830718,5.73,565.07136,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ ACT-O-VIAL,RX-4081057,CDM,J2930,HCPCS,636,RC,00009-0003-02,NDC,outpatient,1,UN,180.85,126.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.785895,5.73,565.07136,percent of total billed charges,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.591131,89.15,17236.24704,percent of total billed charges,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.223777,89.15,17236.24704,percent of total billed charges,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5806.011861,89.15,17236.24704,percent of total billed charges,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2903.009811,89.15,17236.24704,percent of total billed charges,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,48.276007,31.57,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.360935,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.360935,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.572896,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.919554,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.891097,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.572896,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.434367,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.891097,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.919554,0.84,416.02,percent of total billed charges,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.434367,0.84,416.02,percent of total billed charges,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5013.823308,152.7,14884.48512,percent of total billed charges,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.660854,1.358225,416.02,percent of total billed charges,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.565135,1.358225,416.02,percent of total billed charges,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.565135,1.358225,416.02,percent of total billed charges,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.660854,1.358225,416.02,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.862066,14.63291,416.02,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.862066,14.63291,416.02,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.952535,14.63291,416.02,percent of total billed charges,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.952535,14.63291,416.02,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1411.775053,399.86,4191.12192,percent of total billed charges,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.956042,0.52,416.02,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,78.047203,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,187.073731,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,51.344189,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,132.966626,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.483389,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.895393,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.105826,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,73.908003,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,56.756193,3.83,567.65184,percent of total billed charges,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,191.212931,3.83,567.65184,percent of total billed charges,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,51.538214,44.72489,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.375904,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.016691,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.554538,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.554538,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.141787,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.016691,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.708762,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.646176,0.882285,416.02,percent of total billed charges,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.708762,0.882285,416.02,percent of total billed charges,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.884335,5.91,5460.64128,percent of total billed charges,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1839.411327,5.91,5460.64128,percent of total billed charges,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,919.699196,5.91,5460.64128,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.859977,0.9,416.02,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.95995,0.9,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.489538,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.426281,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.432548,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.489538,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.426281,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.432548,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.638415,5.25,416.02,percent of total billed charges,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.638415,5.25,416.02,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.916891,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.098479,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.186133,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.582395,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.0729,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.768858,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.695578,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.991167,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.194945,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.894853,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.894853,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.194945,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,94.332368,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.011614,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.538159,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.403247,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.403247,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.989154,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.989154,2.16,672.6528,percent of total billed charges,
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.522249,2.16,672.6528,percent of total billed charges,
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6188.044499,22.26,18370.38336,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.288423,12.41,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.192607,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.019278,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.210716,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.192607,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.019278,0.88453,416.02,percent of total billed charges,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.88453,416.02,percent of total billed charges,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.217979,4.528165,416.02,percent of total billed charges,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.217979,4.528165,416.02,percent of total billed charges,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.598766,1.15,416.02,percent of total billed charges,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.598766,1.15,416.02,percent of total billed charges,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.801721,1.15,416.02,percent of total billed charges,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.801721,1.15,416.02,percent of total billed charges,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,639.29944,5.69,1897.8816,percent of total billed charges,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.391405,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.39449,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.126611,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.429539,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.126611,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.126611,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.429539,2.51,416.02,percent of total billed charges,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.39449,2.51,416.02,percent of total billed charges,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.302105,0.78,416.02,percent of total billed charges,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.284667,0.78,416.02,percent of total billed charges,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.315504,0.78,416.02,percent of total billed charges,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.140715,0.78,416.02,percent of total billed charges,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.646695,0.36,416.02,percent of total billed charges,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.646695,0.36,416.02,percent of total billed charges,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.646695,0.36,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.86448,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.86448,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.735379,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.393397,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.336234,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.728538,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.400238,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.394815,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.393397,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.39882,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.336234,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.463495,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.394815,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.895275,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.895275,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.412502,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.689311,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.412502,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.689311,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.334567,0.47,416.02,percent of total billed charges,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.47,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.93316,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.551204,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.781447,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.93316,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.724533,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.063679,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.996417,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.676376,0.1,416.02,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.676376,0.1,416.02,percent of total billed charges,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.895275,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.197705,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.197705,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.603961,1.51,416.02,percent of total billed charges,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.603961,1.51,416.02,percent of total billed charges,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.534804,7.43,416.02,percent of total billed charges,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.534804,7.43,416.02,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.898111,6.47,416.02,percent of total billed charges,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.194641,6.47,416.02,percent of total billed charges,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.805747,6.47,416.02,percent of total billed charges,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3485.522014,399.86,10347.43296,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,2.54,416.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.133777,2.54,416.02,percent of total billed charges,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,1.14,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.735379,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.934578,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.797218,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.869903,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.4675,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.133777,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.797218,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.4675,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.04649,1.81,416.02,percent of total billed charges,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.468918,3.62,416.02,percent of total billed charges,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.042831,19.23,416.02,percent of total billed charges,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.042831,19.23,416.02,percent of total billed charges,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.74406,2.39,416.02,percent of total billed charges,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.133777,2.39,416.02,percent of total billed charges,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,2.39,416.02,percent of total billed charges,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,2.39,416.02,percent of total billed charges,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,5.89986,416.02,percent of total billed charges,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,781.84314,2.568211,4642.0992,percent of total billed charges,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1563.68628,2.568211,4642.0992,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,374.8563,1.26,2225.664,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,749.7126,1.26,2225.664,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,471.24792,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,471.24792,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,942.49584,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,942.49584,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,785.4132,1.23,3240,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,785.4132,1.23,3240,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1640.872012,2.13,24356.18304,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1640.872012,2.13,24356.18304,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3281.744024,2.13,24356.18304,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3281.744024,2.13,24356.18304,percent of total billed charges,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8204.354886,2.13,24356.18304,percent of total billed charges,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,481.9581,1.25,2861.568,percent of total billed charges,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,963.9162,1.25,2861.568,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1281.65154,3.35,3804.8256,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1281.65154,3.35,3804.8256,percent of total billed charges,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3587.9103,1.94,10651.392,percent of total billed charges,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,264.885517,73.22,786.36288,percent of total billed charges,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.618293,0.536555,416.02,percent of total billed charges,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.618293,0.536555,416.02,percent of total billed charges,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.955295,15.32,416.02,percent of total billed charges,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.094149,0.52,416.02,percent of total billed charges,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,77.17021,0.52,416.02,percent of total billed charges,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.86,416.02,other,Non-Reimbursable Procedures
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.86,416.02,other,Non-Reimbursable Procedures
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.129738,69.53663,416.02,percent of total billed charges,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.129738,69.53663,416.02,percent of total billed charges,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.650257,0.370425,416.02,percent of total billed charges,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.135693,0.370425,416.02,percent of total billed charges,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.739882,0.370425,416.02,percent of total billed charges,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.833014,0.370425,416.02,percent of total billed charges,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.833014,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.426855,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.030546,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.258451,0.370425,416.02,percent of total billed charges,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.030546,0.370425,416.02,percent of total billed charges,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.512226,0.370425,416.02,percent of total billed charges,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.979477,2.5,525.12,percent of total billed charges,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.091216,2.5,525.12,percent of total billed charges,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.387974,2.5,525.12,percent of total billed charges,
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.159668,2.5,525.12,percent of total billed charges,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,176.886125,2.5,525.12,percent of total billed charges,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,797.564339,7.2,2367.72096,percent of total billed charges,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,797.564339,7.2,2367.72096,percent of total billed charges,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.694582,0.32,416.02,percent of total billed charges,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.361032,0.32,416.02,percent of total billed charges,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.095541,5.43,2152.77312,percent of total billed charges,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,725.159383,5.43,2152.77312,percent of total billed charges,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1313.802776,12.95,3900.27264,percent of total billed charges,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.641975,72.7,7001.856,percent of total billed charges,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2358.5679,72.7,7001.856,percent of total billed charges,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.085392,14.931495,416.02,percent of total billed charges,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.206137,14.931495,416.02,percent of total billed charges,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.18569,1.57,905.322979,percent of total billed charges,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,38.18412,1.57,905.322979,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8362.146364,221.96,24824.61696,percent of total billed charges,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10261.5347,206.03,30463.31136,percent of total billed charges,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.481777,2.41,416.02,percent of total billed charges,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.864252,2.41,416.02,percent of total billed charges,
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2314.242242,47.04,6870.26688,percent of total billed charges,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1131.50206,72.08,3359.0784,percent of total billed charges,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,565.75103,72.08,3359.0784,percent of total billed charges,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.563143,2.37,416.02,percent of total billed charges,
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.955164,14.25,416.02,percent of total billed charges,
CYCLOPHOSPHAMIDE 1 G IJ SOLR,RX-38270,CDM,J9070,HCPCS,636,RC,00781-3244-94,NDC,outpatient,1,UN,1602.63,1121.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,414.600381,17.09,1230.81984,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9070,HCPCS,636,RC,00781-3233-94,NDC,outpatient,1,UN,1017.09,711.963,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,263.121183,17.09,1230.81984,percent of total billed charges,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9070,HCPCS,636,RC,10019-0957-01,NDC,outpatient,1,UN,1524.13,1066.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,394.292431,17.09,1230.81984,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.786123,0.77,416.02,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.593765,0.77,416.02,percent of total billed charges,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.153228,0.77,416.02,percent of total billed charges,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.348747,0.77,416.02,percent of total billed charges,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.348747,0.77,416.02,percent of total billed charges,
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.969129,0.77,416.02,percent of total billed charges,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.253028,3.69078,416.02,percent of total billed charges,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.253028,3.69078,416.02,percent of total billed charges,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,451.229714,4.18,1339.56096,percent of total billed charges,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,289.211078,4.18,1339.56096,percent of total billed charges,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.30746,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.814829,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.186285,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.8162,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.342045,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.95405,0.79,1115.136,percent of total billed charges,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,375.6324,0.79,1115.136,percent of total billed charges,
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.064945,1.34,416.02,percent of total billed charges,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1043.23362,128.78,3097.0368,percent of total billed charges,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.784975,0.7,416.02,percent of total billed charges,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.754408,0.7,416.02,percent of total billed charges,
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.019493,62.498555,604.75,percent of total billed charges,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.779455,1.83,416.02,percent of total billed charges,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.180841,1.83,416.02,percent of total billed charges,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.180841,1.83,416.02,percent of total billed charges,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.130941,2.79,416.02,percent of total billed charges,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.577842,2.79,416.02,percent of total billed charges,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.194447,2.79,416.02,percent of total billed charges,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.437798,2.79,416.02,percent of total billed charges,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,700.254334,399.86,5828.5824,percent of total billed charges,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1963.35191,399.86,5828.5824,percent of total billed charges,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.717443,2.5,416.02,percent of total billed charges,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.801223,2.5,416.02,percent of total billed charges,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.250863,2.5,416.02,percent of total billed charges,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1432.657317,122.55,12759.31392,percent of total billed charges,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4297.961603,122.55,12759.31392,percent of total billed charges,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.408345,21.181575,416.02,percent of total billed charges,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.408345,21.181575,416.02,percent of total billed charges,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,90.790765,21.181575,416.02,percent of total billed charges,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.619428,21.181575,416.02,percent of total billed charges,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.619428,21.181575,416.02,percent of total billed charges,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.336732,1.67,416.02,percent of total billed charges,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.511597,1.67,416.02,percent of total billed charges,
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.499312,27.33512,416.02,percent of total billed charges,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1467.025612,165.86,17420.48256,percent of total billed charges,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4401.040618,165.86,17420.48256,percent of total billed charges,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5868.071404,165.86,17420.48256,percent of total billed charges,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,400.801323,165.86,17420.48256,percent of total billed charges,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6313.037991,167.93,74965.60128,percent of total billed charges,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25252.0847,167.93,74965.60128,percent of total billed charges,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-38,NDC,outpatient,0.5,ML,3.4,2.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.87958,0.27,416.02,percent of total billed charges,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-37,NDC,outpatient,0.5,ML,3.4,2.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.87958,0.27,416.02,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.702246,1.47721,416.02,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.702246,1.47721,416.02,percent of total billed charges,
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,579.995052,72.53,1721.82528,percent of total billed charges,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.044768,0.06,416.02,percent of total billed charges,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.017784,0.06,416.02,percent of total billed charges,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.988167,12.06,3366.45888,percent of total billed charges,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.650797,0.1,416.02,percent of total billed charges,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,112.174907,0.1,416.02,percent of total billed charges,
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1649.960143,399.86,4898.21952,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4194.155641,54.81,12451.14624,percent of total billed charges,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,130.788372,42.51,2565.35808,percent of total billed charges,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,864.138197,42.51,2565.35808,percent of total billed charges,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,864.10974,42.51,2565.35808,percent of total billed charges,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,189.976345,42.51,2565.35808,percent of total billed charges,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.433413,29.06,416.02,percent of total billed charges,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,922.997621,30.46,16440.55296,percent of total billed charges,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2307.484998,30.46,16440.55296,percent of total billed charges,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5537.983139,30.46,16440.55296,percent of total billed charges,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6097.991029,70.55,18103.04256,percent of total billed charges,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4730.30363,149.71,14042.8032,percent of total billed charges,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1182.584962,149.71,14042.8032,percent of total billed charges,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2901.60507,4.18,8613.9648,percent of total billed charges,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,580.321014,4.18,8613.9648,percent of total billed charges,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4829.052007,15.37,14335.95648,percent of total billed charges,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5269.995809,356.51,15644.98176,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1056.722238,68.87,15685.39392,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5283.608603,68.87,15685.39392,percent of total billed charges,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3475.670718,77.31,10318.18752,percent of total billed charges,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,695.134661,77.31,10318.18752,percent of total billed charges,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,303.193813,223.44,900.08832,percent of total billed charges,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1435.601323,32.21,4261.85472,percent of total billed charges,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.113123,0.5,416.02,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.437067,38.33,13677.02016,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4607.089994,38.33,13677.02016,percent of total billed charges,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1229.862387,77.94,3651.07968,percent of total billed charges,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,1152.997443,77.94,3651.07968,percent of total billed charges,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.899972,3.95,416.02,percent of total billed charges,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.907961,7.49,416.02,percent of total billed charges,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.890945,7.49,416.02,percent of total billed charges,
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.175861,7.59,416.02,percent of total billed charges,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,134.024709,1.65,1060,percent of total billed charges,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,134.024709,1.65,1060,percent of total billed charges,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.41367,416.02,other,Non-Reimbursable Procedures
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.41367,416.02,other,Non-Reimbursable Procedures
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.41367,416.02,other,Non-Reimbursable Procedures
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.41367,416.02,other,Non-Reimbursable Procedures
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.03643,1222.676,other,Non-Reimbursable Procedures
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.03643,1222.676,other,Non-Reimbursable Procedures
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.03643,1222.676,other,Non-Reimbursable Procedures
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.579235,416.02,other,Non-Reimbursable Procedures
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.579235,416.02,other,Non-Reimbursable Procedures
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.579235,416.02,other,Non-Reimbursable Procedures
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.579235,416.02,other,Non-Reimbursable Procedures
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.004102,16.49177,416.02,percent of total billed charges,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.004102,16.49177,416.02,percent of total billed charges,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.004102,16.49177,416.02,percent of total billed charges,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.76675,416.02,other,Non-Reimbursable Procedures
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.76675,416.02,other,Non-Reimbursable Procedures
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.76675,416.02,other,Non-Reimbursable Procedures
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.76675,416.02,other,Non-Reimbursable Procedures
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,335.72,5377.9968,other,Non-Reimbursable Procedures
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.661449,15.326615,416.02,percent of total billed charges,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.971142,15.326615,416.02,percent of total billed charges,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.971142,15.326615,416.02,percent of total billed charges,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.225885,416.02,other,Non-Reimbursable Procedures
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.225885,416.02,other,Non-Reimbursable Procedures
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.225885,416.02,other,Non-Reimbursable Procedures
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.724824,50.613525,568.638,percent of total billed charges,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.724824,50.613525,568.638,percent of total billed charges,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.260582,50.613525,568.638,percent of total billed charges,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.260582,50.613525,568.638,percent of total billed charges,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,58.323915,50.613525,568.638,percent of total billed charges,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,71.03902,50.613525,568.638,percent of total billed charges,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.607738,50.613525,568.638,percent of total billed charges,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.621171,50.613525,568.638,percent of total billed charges,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.61,416.02,other,Non-Reimbursable Procedures
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,125.65,1058.40384,other,Non-Reimbursable Procedures
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,125.65,1058.40384,other,Non-Reimbursable Procedures
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3409.78176,other,Non-Reimbursable Procedures
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,252.25,3748.3008,other,Non-Reimbursable Procedures
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,252.25,3748.3008,other,Non-Reimbursable Procedures
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,70.737705,686.06,other,Non-Reimbursable Procedures
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3534.81216,other,Non-Reimbursable Procedures
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3534.81216,other,Non-Reimbursable Procedures
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2191.452874,163.74581,6505.74336,percent of total billed charges,
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1811.57262,163.74581,6505.74336,percent of total billed charges,
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.690606,163.74581,6505.74336,percent of total billed charges,
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,452.510279,163.74581,6505.74336,percent of total billed charges,
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1290.05929,163.74581,6505.74336,percent of total billed charges,
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1125.37087,163.74581,6505.74336,percent of total billed charges,
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,163.74581,6505.74336,percent of total billed charges,
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,163.74581,6505.74336,percent of total billed charges,
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,163.74581,6505.74336,percent of total billed charges,
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,366.2,,,366.2,326.6475,1117.44,fee schedule,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,317.4249,49.4,942.336,percent of total billed charges,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,142.5437,123.6995,423.168,percent of total billed charges,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,98.0473,71.53,416.02,percent of total billed charges,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,121.8477,105.7395,416.02,percent of total billed charges,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,265.9436,163,871.3328,percent of total billed charges,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,361.4039,136.61,1072.896,percent of total billed charges,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.4571,163,1384.1308,percent of total billed charges,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,318.9771,163,1119.53,percent of total billed charges,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.1288,163,1476.21,percent of total billed charges,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,668.9982,163,2191.8936,percent of total billed charges,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,164.5332,142.782,598.2,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.431725,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.570254,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,89.79477,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.178773,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,51.628759,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,51.628759,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.178773,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.570254,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.93397,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.431725,25.321355,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.218346,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.544363,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.998721,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.570254,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,8.405163,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,107.17941,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.11939,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.570254,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.998721,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.31861,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,75.98019,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,78.859521,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,78.859521,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.544363,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.218346,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.11939,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,8.405163,7.294005,416.02,percent of total billed charges,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,75.98019,7.294005,416.02,percent of total billed charges,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,467.4709,163,1698,percent of total billed charges,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,533.4394,163,1747.7512,percent of total billed charges,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,319.4945,163,1046.786,percent of total billed charges,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.4314,49.839,416.02,percent of total billed charges,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.6462,163,1265.41,percent of total billed charges,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.0243,19.9805,416.02,percent of total billed charges,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.655177,0.34,726.30528,percent of total billed charges,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.406159,0.01,416.02,percent of total billed charges,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.01,416.02,percent of total billed charges,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.01,416.02,percent of total billed charges,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.01,416.02,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.920972,0.35,416.02,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.920972,0.35,416.02,percent of total billed charges,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.868734,0.73,416.02,percent of total billed charges,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.868734,0.73,416.02,percent of total billed charges,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.09,416.02,percent of total billed charges,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.09,416.02,percent of total billed charges,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.157904,2.55,416.02,percent of total billed charges,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.109325,2.55,416.02,percent of total billed charges,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.109325,2.55,416.02,percent of total billed charges,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.157904,2.55,416.02,percent of total billed charges,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.270912,87.98,1653.428703,percent of total billed charges,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,364.363428,87.98,1653.428703,percent of total billed charges,
HC Telehealth Originating Site Facility Fee,PX-78000001,CDM,Q3014,HCPCS,780,RC,,,outpatient,,,373,261.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,83.7385,416.02,other,Non-Reimbursable Procedures
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,348.861775,3862.93248,other,Non-Reimbursable Procedures
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,348.861775,3862.93248,other,Non-Reimbursable Procedures
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,348.861775,3862.93248,other,Non-Reimbursable Procedures
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,348.861775,3862.93248,other,Non-Reimbursable Procedures
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,30.42,6716.16,other,Non-Reimbursable Procedures
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.25,659.42016,other,Non-Reimbursable Procedures
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.25,659.42016,other,Non-Reimbursable Procedures
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.96,24594.91584,other,Non-Reimbursable Procedures
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.96,24594.91584,other,Non-Reimbursable Procedures
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.96,24594.91584,other,Non-Reimbursable Procedures
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.5,8051.0208,other,Non-Reimbursable Procedures
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.5,8051.0208,other,Non-Reimbursable Procedures
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.5,8051.0208,other,Non-Reimbursable Procedures
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,46.98,6518.784,percent of total billed charges,
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.16,4034.304,other,Non-Reimbursable Procedures
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.16,4034.304,other,Non-Reimbursable Procedures
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.4745,3643.99872,other,Non-Reimbursable Procedures
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.4745,3643.99872,other,Non-Reimbursable Procedures
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.4745,3643.99872,other,Non-Reimbursable Procedures
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.4745,3643.99872,other,Non-Reimbursable Procedures
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,102.28,3422.3616,percent of total billed charges,
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,102.28,3422.3616,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,156.032318,0.18,741.12768,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,156.024557,0.18,741.12768,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,156.032318,0.18,741.12768,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,249.648087,0.18,741.12768,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,249.648087,0.18,741.12768,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,359.505042,13.62,1653.428703,percent of total billed charges,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,492.145706,27.18,1653.428703,percent of total billed charges,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,492.145706,27.18,1653.428703,percent of total billed charges,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.556302,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.556302,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.834453,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.834453,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.112604,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.112604,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,97.71099,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,97.71099,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.542198,7.5,416.02,percent of total billed charges,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.542198,7.5,416.02,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.518614,33.59,7269.974281,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1723.555119,33.59,7269.974281,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,535.891876,21.29,1590.89664,percent of total billed charges,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,40.92,438.4896,other,Non-Reimbursable Procedures
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,40.92,438.4896,other,Non-Reimbursable Procedures
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.22,416.02,other,Non-Reimbursable Procedures
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.56,416.02,other,Non-Reimbursable Procedures
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.56,416.02,other,Non-Reimbursable Procedures
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.38,416.02,other,Non-Reimbursable Procedures
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.38,416.02,other,Non-Reimbursable Procedures
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.38,416.02,other,Non-Reimbursable Procedures
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.38,416.02,other,Non-Reimbursable Procedures
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.53,2181.7344,other,Non-Reimbursable Procedures
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.53,2181.7344,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-30,NDC,outpatient,650,ME,11.57,8.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-21,NDC,outpatient,650,ME,11.57,8.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-00,NDC,outpatient,650,ME,11.57,8.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-20,NDC,outpatient,650,ME,11.57,8.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,99999-0004-18,NDC,outpatient,2.5,ML,4.86,3.402,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,70954-0316-10,NDC,outpatient,50,ML,117.71,82.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,00904-7193-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,63739-0645-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,62332-0001-31,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FELBAMATE 600 MG ORAL TABS,RX-10025,CDM,S5000,HCPCS,259,RC,72578-0057-16,NDC,outpatient,1,UN,5.99,4.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-06,NDC,outpatient,1,UN,1.66,1.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-01,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-11,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-61,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,00054-0011-21,NDC,outpatient,1,UN,2.98,2.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-11,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-15,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-15,NDC,outpatient,1,UN,3.66,2.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,00054-0010-20,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-11,NDC,outpatient,1,UN,3.66,2.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-11,NDC,outpatient,1,UN,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,00904-6500-61,NDC,outpatient,1,UN,4.03,2.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-01,NDC,outpatient,1,UN,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUCONAZOLE 200 MG ORAL TABS,RX-10045,CDM,S5000,HCPCS,259,RC,00904-6501-61,NDC,outpatient,1,UN,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-11,NDC,outpatient,1,UN,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-15,NDC,outpatient,1,UN,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,64380-0737-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUCYTOSINE 500 MG ORAL CAPS,RX-10052,CDM,S5000,HCPCS,259,RC,42794-0010-08,NDC,outpatient,1,UN,233.01,163.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,00115-7033-01,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-11,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-15,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,16729-0542-35,NDC,outpatient,40,GR,458.18,320.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,51672-4118-06,NDC,outpatient,40,GR,108.41,75.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOXETINE HCL 10 MG ORAL CAPS,RX-10069,CDM,S5000,HCPCS,259,RC,16714-0720-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOXETINE HCL 20 MG ORAL CAPS,RX-10070,CDM,S5000,HCPCS,259,RC,00904-7346-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLURBIPROFEN SODIUM 0.03 % OP SOLN,RX-10080,CDM,S5000,HCPCS,259,RC,69292-0722-25,NDC,outpatient,2.5,ML,140.89,98.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUVOXAMINE MALEATE 50 MG ORAL TABS,RX-10085,CDM,S5000,HCPCS,259,RC,60505-0165-01,NDC,outpatient,1,UN,1.63,1.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOSINOPRIL SODIUM 10 MG ORAL TABS,RX-10094,CDM,S5000,HCPCS,259,RC,69097-0856-05,NDC,outpatient,1,UN,1.76,1.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RITONAVIR 100 MG ORAL TABS,RX-100995,CDM,S5000,HCPCS,259,RC,00074-2340-30,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,60505-0141-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,00904-6637-61,NDC,outpatient,1,UN,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLYBURIDE 2.5 MG ORAL TABS,RX-10126,CDM,S5000,HCPCS,259,RC,00093-8343-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLYCOPYRROLATE 1 MG ORAL TABS,RX-10130,CDM,S5000,HCPCS,259,RC,23155-0606-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-59,NDC,outpatient,1,UN,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-62,NDC,outpatient,1,UN,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 500 MG ORAL TABS,RX-102,CDM,S5000,HCPCS,259,RC,00904-6730-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,59762-0073-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,64380-0970-25,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-11,NDC,outpatient,60,ML,88.11,61.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-07,NDC,outpatient,60,ML,88.11,61.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE MICRONIZED POWD,RX-10217,CDM,S5000,HCPCS,259,RC,51552-0020-05,NDC,outpatient,100,GR,1580.42,1106.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-11,NDC,outpatient,1,UN,4.87,3.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,00904-7046-61,NDC,outpatient,1,UN,3.27,2.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-01,NDC,outpatient,1,UN,4.87,3.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-01,NDC,outpatient,1,UN,3.02,2.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-11,NDC,outpatient,1,UN,3.02,2.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-47,NDC,outpatient,473,ML,67.36,47.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-61,NDC,outpatient,5,ML,2.54,1.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-05,NDC,outpatient,5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,51672-2130-08,NDC,outpatient,120,ML,11.22,7.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-62,NDC,outpatient,5,ML,2.59,1.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,99999-0004-24,NDC,outpatient,5,ML,1.37,0.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-00,NDC,outpatient,5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-05,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-59,NDC,outpatient,5,ML,2.54,1.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-00,NDC,outpatient,5,ML,1398.02,978.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-05,NDC,outpatient,5,ML,1398.02,978.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-01,NDC,outpatient,1,UN,501.97,351.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-02,NDC,outpatient,1,UN,501.97,351.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDOMETHACIN SODIUM 1 MG IV SOLR,RX-10267,CDM,S5000,HCPCS,250,RC,63323-0659-03,NDC,outpatient,1,UN,1192.43,834.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,S5000,HCPCS,259,RC,00002-8315-01,NDC,outpatient,10,ML,61.5,43.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,S5000,HCPCS,259,RC,00002-8215-01,NDC,outpatient,10,ML,61.5,43.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,S5000,HCPCS,259,RC,45802-0732-30,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00472-0370-15,NDC,outpatient,15,GR,93.12,65.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00713-0326-15,NDC,outpatient,15,GR,50.4,35.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,S5000,HCPCS,259,RC,00168-0041-60,NDC,outpatient,60,ML,267,186.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOSORBIDE MONONITRATE 20 MG ORAL TABS,RX-10357,CDM,S5000,HCPCS,259,RC,00228-2620-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISRADIPINE 5 MG ORAL CAPS,RX-10363,CDM,S5000,HCPCS,259,RC,16252-0540-01,NDC,outpatient,1,UN,8.59,6.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ITRACONAZOLE 100 MG ORAL CAPS,RX-10364,CDM,S5000,HCPCS,259,RC,16714-0743-02,NDC,outpatient,1,UN,5.65,3.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,S5000,HCPCS,259,RC,00168-0099-15,NDC,outpatient,15,GR,22.57,15.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,70710-1710-01,NDC,outpatient,1,UN,3.63,2.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,00093-0314-01,NDC,outpatient,1,UN,4.33,3.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-11,NDC,outpatient,1,UN,1.32,0.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-01,NDC,outpatient,1,UN,1.32,0.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-11,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-01,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,63044-0484-09,NDC,outpatient,225,GR,29.04,20.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,00904-5984-26,NDC,outpatient,226,GR,13.08,9.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,16864-0000-18,NDC,outpatient,225,GR,41.06,28.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,30781-7098-79,NDC,outpatient,225,GR,41.06,28.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,51672-1300-05,NDC,outpatient,225,GR,61.08,42.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,57237-0014-01,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,63739-0567-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-01,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,72603-0115-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-11,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-02,NDC,outpatient,1,UN,2.7,1.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-04,NDC,outpatient,1,UN,1.99,1.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-01,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-11,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-20,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-01,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,69238-1835-01,NDC,outpatient,1,UN,1.64,1.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-01,NDC,outpatient,1,UN,2.79,1.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-20,NDC,outpatient,1,UN,2.79,1.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00074-3727-90,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00378-1823-77,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00527-3287-46,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-01,NDC,outpatient,1,UN,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-20,NDC,outpatient,1,UN,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-02,NDC,outpatient,30,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-16,NDC,outpatient,30,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-04,NDC,outpatient,2,ML,4.85,3.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-97,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-01,NDC,outpatient,5,ML,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-26,NDC,outpatient,5,ML,4.55,3.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0159-74,NDC,outpatient,5,ML,3.68,2.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-25,NDC,outpatient,5,ML,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-02,NDC,outpatient,5,ML,4.55,3.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-08,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-09,NDC,outpatient,5,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-27,NDC,outpatient,2,ML,4.85,3.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-57,NDC,outpatient,5,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-12,NDC,outpatient,5,ML,4.55,3.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0163-30,NDC,outpatient,30,ML,6.17,4.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-01,NDC,outpatient,5,ML,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-05,NDC,outpatient,5,ML,11.34,7.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-12,NDC,outpatient,10,ML,10.34,7.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0165-05,NDC,outpatient,5,ML,4.63,3.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-27,NDC,outpatient,2,ML,8.69,6.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-25,NDC,outpatient,5,ML,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-01,NDC,outpatient,2,ML,4.57,3.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-11,NDC,outpatient,2,ML,4.57,3.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-07,NDC,outpatient,5,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-97,NDC,outpatient,10,ML,28.48,19.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-10,NDC,outpatient,5,ML,11.34,7.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-02,NDC,outpatient,10,ML,10.34,7.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0164-02,NDC,outpatient,2,ML,4.16,2.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-04,NDC,outpatient,5,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-03,NDC,outpatient,10,ML,28.48,19.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-25,NDC,outpatient,2,ML,4.57,3.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-09,NDC,outpatient,2,ML,8.69,6.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-57,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-16,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-16,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-17,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-03,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-27,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-02,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-17,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-07,NDC,outpatient,30,ML,30.31,21.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-37,NDC,outpatient,30,ML,30.31,21.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-01,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-89,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-27,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-11,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-03,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-01,NDC,outpatient,20,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-02,NDC,outpatient,20,ML,30.18,21.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-17,NDC,outpatient,10,ML,19.13,13.391,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-11,NDC,outpatient,20,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-27,NDC,outpatient,20,ML,30.18,21.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-01,NDC,outpatient,1,UN,2.51,1.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-89,NDC,outpatient,1,UN,2.51,1.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN,RX-10442,CDM,S5000,HCPCS,250,RC,39822-0151-01,NDC,outpatient,1,ML,1739.29,1217.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,00093-2179-01,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,68382-0582-01,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,00904-6798-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-03,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LISINOPRIL 5 MG ORAL TABS,RX-10451,CDM,S5000,HCPCS,259,RC,00904-6797-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-01,NDC,outpatient,1,UN,1.52,1.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-11,NDC,outpatient,1,UN,1.52,1.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68462-0224-01,NDC,outpatient,1,UN,1,0.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-01,NDC,outpatient,1,UN,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-11,NDC,outpatient,1,UN,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-13,NDC,outpatient,1,UN,11.87,8.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,62559-0265-30,NDC,outpatient,1,UN,10.97,7.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,69918-0301-30,NDC,outpatient,1,UN,6.2,4.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-11,NDC,outpatient,1,UN,11.87,8.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-03,NDC,outpatient,1,UN,223.91,156.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-02,NDC,outpatient,1,UN,223.91,156.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,00904-6852-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,59762-1001-01,NDC,outpatient,1,UN,20.25,14.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,68382-0520-01,NDC,outpatient,1,UN,18.05,12.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAFENIDE ACETATE 85 MG/GM EX CREA,RX-10478,CDM,S5000,HCPCS,259,RC,16571-0723-60,NDC,outpatient,56.7,GR,282.85,197.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,25021-0602-03,NDC,outpatient,3,ML,26.44,18.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-03,NDC,outpatient,3,ML,31.83,22.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,51754-0501-03,NDC,outpatient,3,ML,27.32,19.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-01,NDC,outpatient,3,ML,31.83,22.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM OXIDE 140 MG ORAL CAPS,RX-10490,CDM,S5000,HCPCS,259,RC,60569-0495-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-33,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-30,NDC,outpatient,1,UN,1.95,1.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-03,NDC,outpatient,946,ML,46.31,32.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-04,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-13,NDC,outpatient,946,ML,46.31,32.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-05,NDC,outpatient,15,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE ER 250 MG ORAL CPCR,RX-10533,CDM,S5000,HCPCS,259,RC,54092-0189-81,NDC,outpatient,1,UN,12.49,8.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BROMOCRIPTINE MESYLATE 0.8 MG ORAL TABS,RX-105409,CDM,S5000,HCPCS,259,RC,68012-0258-20,NDC,outpatient,1,UN,23.23,16.261,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,00904-7162-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,99999-0001-42,NDC,outpatient,20,ML,187.97,131.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,00131-5410-72,NDC,outpatient,5,ML,47,32.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-11,NDC,outpatient,1,UN,7.92,5.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-21,NDC,outpatient,1,UN,7.92,5.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,23155-0070-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-11,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-01,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-01,NDC,outpatient,10,ML,18.15,12.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-02,NDC,outpatient,30,ML,28.84,20.188,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-10,NDC,outpatient,10,ML,17.38,12.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-71,NDC,outpatient,30,ML,36.85,25.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-11,NDC,outpatient,10,ML,18.15,12.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-17,NDC,outpatient,10,ML,18.16,12.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-70,NDC,outpatient,10,ML,17.38,12.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-01,NDC,outpatient,10,ML,18.16,12.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-37,NDC,outpatient,30,ML,28.84,20.188,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-30,NDC,outpatient,30,ML,36.85,25.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-11,NDC,outpatient,10,ML,11.21,7.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-31,NDC,outpatient,30,ML,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-37,NDC,outpatient,30,ML,30.98,21.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-17,NDC,outpatient,30,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-01,NDC,outpatient,30,ML,30.98,21.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-02,NDC,outpatient,30,ML,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-04,NDC,outpatient,10,ML,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-17,NDC,outpatient,10,ML,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-01,NDC,outpatient,10,ML,11.21,7.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-16,NDC,outpatient,30,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-02,NDC,outpatient,1,UN,78.51,54.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-11,NDC,outpatient,1,UN,190.6,133.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-94,NDC,outpatient,1,UN,190.6,133.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-08,NDC,outpatient,1,UN,71.96,50.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-01,NDC,outpatient,1,UN,11.25,7.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-20,NDC,outpatient,1,UN,11.25,7.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-01,NDC,outpatient,1,UN,12.79,8.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-20,NDC,outpatient,1,UN,12.79,8.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,S5000,HCPCS,259,RC,16714-0557-01,NDC,outpatient,70,GR,66.67,46.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,62559-0820-01,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,00093-8739-01,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,50742-0239-01,NDC,outpatient,1,UN,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEXILETINE HCL 200 MG ORAL CAPS,RX-10596,CDM,S5000,HCPCS,259,RC,00093-8740-01,NDC,outpatient,1,UN,3.1,2.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,53329-0169-79,NDC,outpatient,85,GR,16.27,11.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,11701-0038-16,NDC,outpatient,85,GR,25.73,18.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MICROFIBRILLAR COLL HEMOSTAT EX PADS,RX-10605,CDM,S5000,HCPCS,259,RC,53276-1010-08,NDC,outpatient,1,UN,496.85,347.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,S5000,HCPCS,250,RC,53276-1010-02,NDC,outpatient,1,GR,993.69,695.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ULIPRISTAL ACETATE 30 MG ORAL TABS,RX-106079,CDM,S5000,HCPCS,259,RC,73302-0456-01,NDC,outpatient,1,UN,159.36,111.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00245-0211-11,NDC,outpatient,1,UN,1.99,1.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00378-1901-01,NDC,outpatient,1,UN,2.12,1.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-01,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-01,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-89,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-20,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00904-6818-61,NDC,outpatient,1,UN,2.24,1.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,63739-0145-10,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-106248,CDM,S5000,HCPCS,259,RC,24208-0830-60,NDC,outpatient,5,ML,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-106249,CDM,S5000,HCPCS,259,RC,61314-0631-36,NDC,outpatient,3.5,GR,69.78,48.846,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,59762-5007-01,NDC,outpatient,1,UN,2.08,1.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-11,NDC,outpatient,1,UN,9.27,6.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,00025-1451-34,NDC,outpatient,1,UN,17.24,12.068,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-01,NDC,outpatient,1,UN,9.27,6.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-11,NDC,outpatient,1,UN,7.19,5.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-01,NDC,outpatient,1,UN,7.19,5.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-01,NDC,outpatient,50,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-16,NDC,outpatient,50,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-56,NDC,outpatient,1,UN,12.92,9.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-61,NDC,outpatient,1,UN,12.92,9.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-82,NDC,outpatient,1,UN,12.92,9.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-55,NDC,outpatient,1,UN,12.92,9.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,99999-0002-18,NDC,outpatient,1,ML,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,00406-8003-30,NDC,outpatient,0.25,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,68462-0180-22,NDC,outpatient,22,GR,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,45802-0112-22,NDC,outpatient,22,GR,13.61,9.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,51672-1312-00,NDC,outpatient,22,GR,11.07,7.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-21,NDC,outpatient,1,UN,3.85,2.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,00591-3670-01,NDC,outpatient,1,UN,1.2,0.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-11,NDC,outpatient,1,UN,3.85,2.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00904-7036-04,NDC,outpatient,1,UN,7.95,5.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-21,NDC,outpatient,1,UN,8.68,6.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00406-1170-03,NDC,outpatient,1,UN,4.49,3.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-11,NDC,outpatient,1,UN,8.68,6.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,68462-0120-90,NDC,outpatient,1,UN,18.98,13.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,62559-0205-90,NDC,outpatient,1,UN,35.49,24.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,68462-0121-90,NDC,outpatient,1,UN,27.58,19.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,42806-0502-09,NDC,outpatient,1,UN,24.73,17.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-1362-23,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-3029-23,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00135-0242-08,NDC,outpatient,1,UN,2.37,1.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00536-1372-23,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-11,NDC,outpatient,1,UN,5.11,3.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-00,NDC,outpatient,1,UN,5.11,3.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-15,NDC,outpatient,1,UN,7.34,5.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,16714-0439-01,NDC,outpatient,1,UN,7.17,5.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-11,NDC,outpatient,1,UN,7.34,5.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,00904-7137-61,NDC,outpatient,1,UN,6.96,4.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-01,NDC,outpatient,1,UN,9.67,6.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-11,NDC,outpatient,1,UN,9.67,6.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,42858-0750-40,NDC,outpatient,1,UN,220.77,154.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-04,NDC,outpatient,1,UN,146.92,102.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-01,NDC,outpatient,1,UN,146.92,102.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-40,NDC,outpatient,1,UN,232.52,162.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-21,NDC,outpatient,1,UN,232.52,162.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLSALAZINE SODIUM 250 MG ORAL CAPS,RX-10773,CDM,S5000,HCPCS,259,RC,00037-6860-10,NDC,outpatient,1,UN,61.39,42.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-00,NDC,outpatient,5,ML,4.92,3.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-40,NDC,outpatient,5,ML,7.15,5.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-05,NDC,outpatient,5,ML,7.15,5.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,99999-0001-41,NDC,outpatient,5,ML,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISACODYL 5 MG ORAL TBEC,RX-1079,CDM,S5000,HCPCS,259,RC,00904-6407-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-12,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-50,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,81421-0021-03,NDC,outpatient,1,UN,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-50,NDC,outpatient,1,UN,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-02,NDC,outpatient,2.5,GR,13.58,9.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-01,NDC,outpatient,2.5,GR,13.58,9.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-30,NDC,outpatient,5,GR,13.67,9.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-26,NDC,outpatient,5,GR,13.67,9.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,00406-8557-30,NDC,outpatient,30,ML,133.24,93.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,99999-0002-27,NDC,outpatient,1,ML,7.21,5.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-55,NDC,outpatient,5,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-05,NDC,outpatient,5,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-23,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,10702-0018-50,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-11,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00904-6966-61,NDC,outpatient,1,UN,1.01,0.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-62,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,42858-0001-10,NDC,outpatient,1,UN,1,0.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAROXETINE HCL 20 MG ORAL TABS,RX-10855,CDM,S5000,HCPCS,259,RC,63739-0963-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISMUTH SUBCARBONATE POWD,RX-1086,CDM,S5000,HCPCS,259,RC,62991-2844-02,NDC,outpatient,100,GR,276.06,193.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,99999-0001-91,NDC,outpatient,30,ML,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,37000-0475-08,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PERMETHRIN 5 % EX CREA,RX-10917,CDM,S5000,HCPCS,259,RC,00472-0242-60,NDC,outpatient,60,GR,76.37,53.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00310-0095-30,NDC,outpatient,1,UN,54.75,38.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,31722-0623-90,NDC,outpatient,1,UN,7.15,5.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,42571-0259-30,NDC,outpatient,1,UN,4.47,3.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00378-1905-77,NDC,outpatient,1,UN,17.44,12.208,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-11,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-21,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOXYBENZAMINE HCL 10 MG ORAL CAPS,RX-10945,CDM,S5000,HCPCS,259,RC,66993-0066-02,NDC,outpatient,1,UN,73.53,51.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-01,NDC,outpatient,1,UN,1208.89,846.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-10,NDC,outpatient,1,UN,1233.54,863.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LINAGLIPTIN 5 MG ORAL TABS,RX-109773,CDM,S5000,HCPCS,259,RC,00597-0140-61,NDC,outpatient,1,UN,56.14,39.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RILPIVIRINE HCL 25 MG ORAL TABS,RX-109909,CDM,S5000,HCPCS,259,RC,59676-0278-01,NDC,outpatient,1,UN,209.04,146.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-25,NDC,outpatient,1,UN,4.05,2.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,00904-7199-07,NDC,outpatient,1,UN,3.73,2.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-95,NDC,outpatient,1,UN,4.05,2.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYTOIN SODIUM EXTENDED 30 MG ORAL CAPS,RX-11019,CDM,S5000,HCPCS,259,RC,00071-3740-66,NDC,outpatient,1,UN,5.97,4.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-94,NDC,outpatient,1,UN,227.6,159.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-11,NDC,outpatient,1,UN,227.6,159.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FIDAXOMICIN 200 MG ORAL TABS,RX-110360,CDM,S5000,HCPCS,259,RC,52015-0080-01,NDC,outpatient,1,UN,501.77,351.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TICAGRELOR 90 MG ORAL TABS,RX-110427,CDM,S5000,HCPCS,259,RC,00186-0777-39,NDC,outpatient,1,UN,30.77,21.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00536-4306-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00904-2500-91,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLYSACCHARIDE IRON COMPLEX 150 MG ORAL CAPS,RX-11050,CDM,S5000,HCPCS,259,RC,00904-5395-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-33,NDC,outpatient,1,UN,8.47,5.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,00178-0610-01,NDC,outpatient,1,UN,7.92,5.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-32,NDC,outpatient,1,UN,8.47,5.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,00004-0822-05,NDC,outpatient,60,ML,624.52,437.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,99999-0000-41,NDC,outpatient,5,ML,52.63,36.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,27241-0139-09,NDC,outpatient,60,ML,35.52,24.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,68180-0678-01,NDC,outpatient,60,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAVASTATIN SODIUM 10 MG ORAL TABS,RX-11110,CDM,S5000,HCPCS,259,RC,00904-5891-61,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,00904-5892-61,NDC,outpatient,1,UN,2.3,1.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-01,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-20,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-01,NDC,outpatient,1,UN,2.64,1.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-11,NDC,outpatient,1,UN,2.64,1.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,S5000,HCPCS,259,RC,00574-7226-12,NDC,outpatient,1,UN,26.18,18.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-12,NDC,outpatient,1,UN,43.38,30.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-06,NDC,outpatient,1,UN,43.38,30.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,S5000,HCPCS,259,RC,00713-0526-12,NDC,outpatient,1,UN,43.38,30.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPAFENONE HCL 150 MG ORAL TABS,RX-11146,CDM,S5000,HCPCS,259,RC,00591-0582-01,NDC,outpatient,1,UN,1.95,1.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPAFENONE HCL 225 MG ORAL TABS,RX-11147,CDM,S5000,HCPCS,259,RC,00591-0583-01,NDC,outpatient,1,UN,1.32,0.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,00904-6622-61,NDC,outpatient,1,UN,3.64,2.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,68382-0659-06,NDC,outpatient,1,UN,1.59,1.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOSTIGMINE BROMIDE ER 180 MG ORAL TBCR,RX-11240,CDM,S5000,HCPCS,259,RC,47781-0335-30,NDC,outpatient,1,UN,71.76,50.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIMETHAMINE 25 MG ORAL TABS,RX-11246,CDM,S5000,HCPCS,259,RC,43598-0672-01,NDC,outpatient,1,UN,1019.51,713.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-00,NDC,outpatient,2,ML,92.93,65.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-05,NDC,outpatient,2,ML,92.93,65.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RAMIPRIL 1.25 MG ORAL CAPS,RX-11258,CDM,S5000,HCPCS,259,RC,68382-0144-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,57237-0224-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,68382-0146-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-21,NDC,outpatient,1,UN,9.33,6.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-11,NDC,outpatient,1,UN,9.33,6.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,68180-0157-01,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIBAVIRIN 200 MG ORAL CAPS,RX-11286,CDM,S5000,HCPCS,259,RC,65862-0290-84,NDC,outpatient,1,UN,5.94,4.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFABUTIN 150 MG ORAL CAPS,RX-11290,CDM,S5000,HCPCS,259,RC,59762-1350-01,NDC,outpatient,1,UN,47.58,33.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,67457-0445-60,NDC,outpatient,1,UN,242,169.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,00068-0597-01,NDC,outpatient,1,UN,360.5,252.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,63323-0351-20,NDC,outpatient,1,UN,246.71,172.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-11,NDC,outpatient,1,UN,10.17,7.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-21,NDC,outpatient,1,UN,10.17,7.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-01,NDC,outpatient,1,UN,6.25,4.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-11,NDC,outpatient,1,UN,6.25,4.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-01,NDC,outpatient,1,UN,9.15,6.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-11,NDC,outpatient,1,UN,9.15,6.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-113082,CDM,S5000,HCPCS,259,RC,00487-5901-99,NDC,outpatient,1,UN,5.79,4.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,99999-9003-64,NDC,outpatient,5,ML,27.75,19.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,65628-0070-03,NDC,outpatient,5,ML,27.75,19.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,00904-6925-61,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-11,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,68180-0352-09,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,76282-0213-18,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-04,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-01,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,16729-0346-10,NDC,outpatient,1,UN,5,3.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,63402-0302-30,NDC,outpatient,1,UN,165.29,115.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,67877-0638-30,NDC,outpatient,1,UN,1.86,1.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,S5000,HCPCS,259,RC,12870-0001-01,NDC,outpatient,10,UN,28.31,19.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-00,NDC,outpatient,30,ML,19.63,13.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-30,NDC,outpatient,30,ML,19.63,13.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-04,NDC,outpatient,1000,ML,15.82,11.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-03,NDC,outpatient,500,ML,11.87,8.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,S5000,HCPCS,259,RC,24208-0276-15,NDC,outpatient,15,ML,65.35,45.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-11,NDC,outpatient,1,UN,4.36,3.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-01,NDC,outpatient,1,UN,4.36,3.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,00093-2210-01,NDC,outpatient,1,UN,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-20,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,59762-0401-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,29033-0003-05,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,62135-0436-90,NDC,outpatient,1,UN,16.45,11.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-01,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,62559-0721-01,NDC,outpatient,1,UN,4.45,3.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,00527-1318-01,NDC,outpatient,1,UN,19.38,13.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-10,NDC,outpatient,2,ML,164.48,115.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-01,NDC,outpatient,2,ML,164.48,115.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-21,NDC,outpatient,1,UN,883.55,618.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-22,NDC,outpatient,1,UN,883.55,618.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,S5000,HCPCS,250,RC,60793-0215-05,NDC,outpatient,1,UN,195.76,137.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,64980-0513-05,NDC,outpatient,5,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,60758-0802-05,NDC,outpatient,5,ML,11.17,7.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,64980-0514-05,NDC,outpatient,5,ML,21.94,15.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,60758-0801-05,NDC,outpatient,5,ML,22.48,15.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,S5000,HCPCS,259,RC,00078-0876-01,NDC,outpatient,3.5,GR,1115.32,780.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,S5000,HCPCS,259,RC,24208-0295-25,NDC,outpatient,2.5,ML,173.64,121.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,59212-0002-01,NDC,outpatient,1,UN,60.49,42.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,66993-0831-02,NDC,outpatient,1,UN,36.58,25.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,S5000,HCPCS,259,RC,61314-0044-75,NDC,outpatient,7.5,ML,948.02,663.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,61314-0628-10,NDC,outpatient,10,ML,43.88,30.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,24208-0315-10,NDC,outpatient,10,ML,47.84,33.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TABS,RX-11599,CDM,S5000,HCPCS,259,RC,00904-2725-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-01,NDC,outpatient,1,UN,15.37,10.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-11,NDC,outpatient,1,UN,15.37,10.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-01,NDC,outpatient,1,UN,11.52,8.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-10,NDC,outpatient,1,UN,11.52,8.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-10,NDC,outpatient,1,UN,41.49,29.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-01,NDC,outpatient,1,UN,41.49,29.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,RX-116728,CDM,S5000,HCPCS,259,RC,00597-0024-02,NDC,outpatient,4,GR,2012.08,1408.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIDOVUDINE 100 MG ORAL CAPS,RX-11692,CDM,S5000,HCPCS,259,RC,65862-0107-01,NDC,outpatient,1,UN,6.23,4.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIDOVUDINE 10 MG/ML ORAL SYRP,RX-11693,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,3.1,2.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZOLPIDEM TARTRATE 5 MG ORAL TABS,RX-11701,CDM,S5000,HCPCS,259,RC,00904-6082-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LINACLOTIDE 145 MCG ORAL CAPS,RX-117352,CDM,S5000,HCPCS,259,RC,00456-1201-30,NDC,outpatient,1,UN,74.11,51.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-01,NDC,outpatient,1,UN,8.83,6.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-16,NDC,outpatient,1,UN,6.86,4.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-93,NDC,outpatient,1,UN,6.86,4.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-07,NDC,outpatient,1,UN,8.83,6.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-01,NDC,outpatient,1,UN,1.46,1.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-62,NDC,outpatient,1,UN,4.35,3.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-23,NDC,outpatient,1,UN,4.35,3.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00904-6558-61,NDC,outpatient,1,UN,5.15,3.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-21,NDC,outpatient,1,UN,6.17,4.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-31,NDC,outpatient,1,UN,6.17,4.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-03,NDC,outpatient,10,ML,102.35,71.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-01,NDC,outpatient,10,ML,30.13,21.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-10,NDC,outpatient,10,ML,30.13,21.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-11,NDC,outpatient,10,ML,30.26,21.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-10,NDC,outpatient,10,ML,30.26,21.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-01,NDC,outpatient,10,ML,102.35,71.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00228-4270-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-23,NDC,outpatient,1,UN,2.2,1.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,63304-0450-01,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-62,NDC,outpatient,1,UN,2.2,1.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-23,NDC,outpatient,1,UN,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-62,NDC,outpatient,1,UN,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5649-01,NDC,outpatient,10,ML,39.65,27.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-02,NDC,outpatient,10,ML,3.96,2.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-09,NDC,outpatient,10,ML,3.96,2.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-28,NDC,outpatient,10,ML,3.96,2.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
APIXABAN 5 MG ORAL TABS,RX-119614,CDM,S5000,HCPCS,259,RC,00003-0894-31,NDC,outpatient,1,UN,6.17,4.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-32,NDC,outpatient,1,UN,23.14,16.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,00023-5853-18,NDC,outpatient,1,UN,15.96,11.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,59762-0117-01,NDC,outpatient,1,UN,10.4,7.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-33,NDC,outpatient,1,UN,23.14,16.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-11,NDC,outpatient,1,UN,1.73,1.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-01,NDC,outpatient,1,UN,1.73,1.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,68462-0721-01,NDC,outpatient,1,UN,5.92,4.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,62332-0025-31,NDC,outpatient,1,UN,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL ER 14 MG ORAL CP24,RX-121474,CDM,S5000,HCPCS,259,RC,00456-3414-33,NDC,outpatient,1,UN,7.56,5.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL ER 21 MG ORAL CP24,RX-121475,CDM,S5000,HCPCS,259,RC,00456-3421-33,NDC,outpatient,1,UN,7.56,5.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL ER 28 MG ORAL CP24,RX-121476,CDM,S5000,HCPCS,259,RC,00456-3428-33,NDC,outpatient,1,UN,63.71,44.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,55494-0100-10,NDC,outpatient,1,UN,13.41,9.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,70505-0100-10,NDC,outpatient,1,UN,13.18,9.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
QUINIDINE GLUCONATE ER 324 MG ORAL TBCR,RX-12197,CDM,S5000,HCPCS,259,RC,53489-0141-01,NDC,outpatient,1,UN,24.15,16.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-25,NDC,outpatient,1,UN,3.98,2.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-95,NDC,outpatient,1,UN,3.98,2.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,57664-0395-88,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-01,NDC,outpatient,1,UN,3.02,2.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-11,NDC,outpatient,1,UN,3.02,2.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-11,NDC,outpatient,1,UN,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-01,NDC,outpatient,1,UN,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-40,NDC,outpatient,2.5,ML,560.63,392.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-39,NDC,outpatient,2.5,ML,560.63,392.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IRON-VITAMIN C 65-125 MG ORAL TABS,RX-122332,CDM,S5000,HCPCS,259,RC,63736-0123-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL ER 10 MG ORAL T12A,RX-122363,CDM,S5000,HCPCS,259,RC,59011-0410-20,NDC,outpatient,1,UN,22.52,15.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-20,NDC,outpatient,1,UN,41.94,29.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-10,NDC,outpatient,1,UN,40.9,28.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL ER 40 MG ORAL T12A,RX-122368,CDM,S5000,HCPCS,259,RC,59011-0440-20,NDC,outpatient,1,UN,71.8,50.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOLUTEGRAVIR SODIUM 50 MG ORAL TABS,RX-122784,CDM,S5000,HCPCS,259,RC,49702-0228-13,NDC,outpatient,1,UN,324.81,227.367,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,65162-0082-03,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,16729-0348-10,NDC,outpatient,1,UN,5,3.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-60,NDC,outpatient,3,ML,9.75,6.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-01,NDC,outpatient,4,ML,26.92,18.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-30,NDC,outpatient,30,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-03,NDC,outpatient,30,ML,57.68,40.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-04,NDC,outpatient,4,ML,17.02,11.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-61,NDC,outpatient,3,ML,9.75,6.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-11,NDC,outpatient,30,ML,57.68,40.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-25,NDC,outpatient,4,ML,26.92,18.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-22,NDC,outpatient,30,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-22,NDC,outpatient,4,ML,17.02,11.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-03,NDC,outpatient,2,ML,9.94,6.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-03,NDC,outpatient,2,ML,11.79,8.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-41,NDC,outpatient,2,ML,9.94,6.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-02,NDC,outpatient,2,ML,21.6,15.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-42,NDC,outpatient,2,ML,21.6,15.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-02,NDC,outpatient,2,ML,11.79,8.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,99999-0004-13,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,51672-4070-08,NDC,outpatient,2.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,70069-0131-01,NDC,outpatient,5,ML,22.25,15.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,61314-0643-05,NDC,outpatient,5,ML,42.15,29.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EXENATIDE 5 MCG/0.02ML SC SOPN,RX-124738,CDM,S5000,HCPCS,259,RC,00310-6512-01,NDC,outpatient,1.2,ML,2102.55,1471.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EXENATIDE 10 MCG/0.04ML SC SOPN,RX-124739,CDM,S5000,HCPCS,259,RC,00310-6524-01,NDC,outpatient,2.4,ML,2102.55,1471.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-12,NDC,outpatient,3,ML,1117.4,782.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-13,NDC,outpatient,3,ML,1117.41,782.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,00555-0899-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,42806-0087-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN 0.3 % OP OINT,RX-125351,CDM,S5000,HCPCS,259,RC,00078-0813-01,NDC,outpatient,3.5,GR,1047.63,733.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL LIQD,RX-12556,CDM,S5000,HCPCS,259,RC,00904-6985-20,NDC,outpatient,2.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-01,NDC,outpatient,2.5,ML,1.51,1.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-60,NDC,outpatient,2.5,ML,1.12,0.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00378-7970-93,NDC,outpatient,2.5,ML,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-83,NDC,outpatient,2.5,ML,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,76204-0100-01,NDC,outpatient,2.5,ML,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-79,NDC,outpatient,2.5,ML,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-125849,CDM,S5000,HCPCS,259,RC,00536-1186-12,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAFFEINE 200 MG ORAL TABS,RX-1259,CDM,S5000,HCPCS,259,RC,46017-0018-40,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DANTROLENE SODIUM 250 MG IV SUSR,RX-126042,CDM,S5000,HCPCS,250,RC,42367-0540-32,NDC,outpatient,1,UN,5868.29,4107.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-30,NDC,outpatient,1,UN,55.29,38.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-37,NDC,outpatient,1,UN,55.29,38.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EMPAGLIFLOZIN 25 MG ORAL TABS,RX-126078,CDM,S5000,HCPCS,259,RC,00597-0153-37,NDC,outpatient,1,UN,55.29,38.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-01,NDC,outpatient,2,ML,107.33,75.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-10,NDC,outpatient,2,ML,107.33,75.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TERBINAFINE HCL 250 MG ORAL TABS,RX-12724,CDM,S5000,HCPCS,259,RC,65862-0079-30,NDC,outpatient,1,UN,1.29,0.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMTERENE-HCTZ 37.5-25 MG ORAL CAPS,RX-12729,CDM,S5000,HCPCS,259,RC,00781-2074-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE IN NACL 20-0.9 MG/50ML-% IV SOLN,RX-12735,CDM,S5000,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-04,NDC,outpatient,5,ML,13.49,9.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-05,NDC,outpatient,5,ML,45.71,31.997,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,99999-0002-29,NDC,outpatient,5,ML,70.67,49.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-04,NDC,outpatient,5,ML,45.71,31.997,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-05,NDC,outpatient,5,ML,13.49,9.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE 7.5 MCG/HR TD PTWK,RX-127562,CDM,S5000,HCPCS,259,RC,42858-0353-40,NDC,outpatient,1,UN,309.07,216.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-25,NDC,outpatient,1,UN,10.51,7.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,00527-1313-01,NDC,outpatient,1,UN,4.2,2.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-95,NDC,outpatient,1,UN,10.51,7.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,RX-128423,CDM,S5000,HCPCS,259,RC,00597-0100-51,NDC,outpatient,4,GR,308.39,215.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENTOSAN POLYSULFATE SODIUM 100 MG ORAL CAPS,RX-12912,CDM,S5000,HCPCS,259,RC,50458-0098-01,NDC,outpatient,1,UN,46.46,32.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,00904-7097-61,NDC,outpatient,1,UN,4.43,3.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-20,NDC,outpatient,1,UN,4.95,3.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-01,NDC,outpatient,1,UN,4.95,3.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOMEBORO EX PACK,RX-129475,CDM,S5000,HCPCS,259,RC,57074-0001-77,NDC,outpatient,1,UN,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DARUNAVIR-COBICISTAT 800-150 MG ORAL TABS,RX-129730,CDM,S5000,HCPCS,259,RC,59676-0575-30,NDC,outpatient,1,UN,354.92,248.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-72,NDC,outpatient,2,ML,130.52,91.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-95,NDC,outpatient,2,ML,130.52,91.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-90,NDC,outpatient,1,UN,23.54,16.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-01,NDC,outpatient,1,UN,42.28,29.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-24,NDC,outpatient,1,UN,23.2,16.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-04,NDC,outpatient,1,UN,23.54,16.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-10,NDC,outpatient,4,ML,15.67,10.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-04,NDC,outpatient,4,ML,24.37,17.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-01,NDC,outpatient,4,ML,15.67,10.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-14,NDC,outpatient,4,ML,23.45,16.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-00,NDC,outpatient,4,ML,24.37,17.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-01,NDC,outpatient,4,ML,19.72,13.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-04,NDC,outpatient,4,ML,23.45,16.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,25021-0316-04,NDC,outpatient,4,ML,19.53,13.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-07,NDC,outpatient,4,ML,19.72,13.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,20555-0005-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,00904-3232-92,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,00536-1202-07,NDC,outpatient,1,UN,3.11,2.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,70512-0812-30,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,41167-0058-40,NDC,outpatient,1,UN,6.13,4.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,59762-1210-03,NDC,outpatient,1,UN,2.76,1.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,68180-0604-06,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-10,NDC,outpatient,10,ML,41.92,29.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-11,NDC,outpatient,10,ML,55.67,38.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,76329-3304-01,NDC,outpatient,10,ML,39.08,27.356,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-34,NDC,outpatient,10,ML,55.67,38.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-40,NDC,outpatient,10,ML,41.92,29.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-01,NDC,outpatient,1,UN,5.2,3.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-11,NDC,outpatient,1,UN,5.2,3.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,68462-0260-01,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-131078,CDM,S5000,HCPCS,259,RC,00597-0155-70,NDC,outpatient,4,GR,308.39,215.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,00904-5823-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG ORAL TABS,RX-131233,CDM,S5000,HCPCS,259,RC,61958-1901-01,NDC,outpatient,1,UN,572.84,400.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,00904-6565-61,NDC,outpatient,1,UN,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,63739-0077-10,NDC,outpatient,1,UN,4,2.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-11,NDC,outpatient,1,UN,4.3,3.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-01,NDC,outpatient,1,UN,4.3,3.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SACUBITRIL-VALSARTAN 24-26 MG ORAL TABS,RX-131630,CDM,S5000,HCPCS,259,RC,00078-0659-20,NDC,outpatient,1,UN,46.68,32.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SACUBITRIL-VALSARTAN 49-51 MG ORAL TABS,RX-131631,CDM,S5000,HCPCS,259,RC,00078-0777-20,NDC,outpatient,1,UN,46.68,32.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SACUBITRIL-VALSARTAN 97-103 MG ORAL TABS,RX-131632,CDM,S5000,HCPCS,259,RC,00078-0696-20,NDC,outpatient,1,UN,46.68,32.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMINOCAPROIC ACID 0.25 GM/ML ORAL SOLN,RX-131645,CDM,S5000,HCPCS,259,RC,99999-0001-90,NDC,outpatient,5,ML,202.39,141.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL ER 120 MG ORAL TBCR,RX-13184,CDM,S5000,HCPCS,259,RC,68462-0292-01,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE (PF) 0.75% -1:200000 IJ SOLN,RX-132205,CDM,S5000,HCPCS,250,RC,63323-0460-37,NDC,outpatient,30,ML,34.71,24.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TICAGRELOR 60 MG ORAL TABS,RX-132286,CDM,S5000,HCPCS,259,RC,00186-0776-60,NDC,outpatient,1,UN,30.77,21.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-9119-44,NDC,outpatient,5,ML,27.82,19.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70004-0430-09,NDC,outpatient,5,ML,28.93,20.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,69374-0982-55,NDC,outpatient,5,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-1119-44,NDC,outpatient,5,ML,20.39,14.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,00904-7119-06,NDC,outpatient,1,UN,3.29,2.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-01,NDC,outpatient,1,UN,5.45,3.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-11,NDC,outpatient,1,UN,5.45,3.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-01,NDC,outpatient,1,UN,29.34,20.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-60,NDC,outpatient,1,UN,29.34,20.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-60,NDC,outpatient,1,UN,46.07,32.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-01,NDC,outpatient,1,UN,46.07,32.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-01,NDC,outpatient,1,UN,70.24,49.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-60,NDC,outpatient,1,UN,70.24,49.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-01,NDC,outpatient,1,UN,72.31,50.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-60,NDC,outpatient,1,UN,72.31,50.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRENATAL VITAMIN PLUS LOW IRON 27-1 MG ORAL TABS,RX-133380,CDM,S5000,HCPCS,259,RC,39328-0106-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMCICLOVIR 500 MG ORAL TABS,RX-13358,CDM,S5000,HCPCS,259,RC,60505-3247-03,NDC,outpatient,1,UN,1.93,1.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,14.6,10.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,14.6,10.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-01,NDC,outpatient,3,ML,1168.7,818.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-27,NDC,outpatient,3,ML,1168.7,818.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EMTRICITABINE-TENOFOVIR AF 200-25 MG ORAL TABS,RX-134420,CDM,S5000,HCPCS,259,RC,61958-2002-01,NDC,outpatient,1,UN,316.88,221.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1007-36,NDC,outpatient,125,ML,77.9,54.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1575-36,NDC,outpatient,125,ML,81.02,56.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70004-0540-35,NDC,outpatient,125,ML,123.38,86.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PSYLLIUM 400 MG ORAL CAPS,RX-134482,CDM,S5000,HCPCS,259,RC,37000-0405-14,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,00904-3854-61,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-01,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-11,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE 100 MG/5ML ORAL SUSP,RX-1356,CDM,S5000,HCPCS,259,RC,99999-0001-92,NDC,outpatient,10,ML,6.06,4.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-01,NDC,outpatient,10,ML,411.18,287.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-05,NDC,outpatient,10,ML,411.18,287.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE 200 MG ORAL TABS,RX-1357,CDM,S5000,HCPCS,259,RC,00904-6172-61,NDC,outpatient,1,UN,2.42,1.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70092-1443-43,NDC,outpatient,1,ML,22.08,15.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,99999-0003-11,NDC,outpatient,1.1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70004-0725-05,NDC,outpatient,1,ML,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70004-0924-59,NDC,outpatient,280,ML,189.24,132.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,99999-0001-84,NDC,outpatient,280,ML,33.42,23.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70092-9056-05,NDC,outpatient,280,ML,121.34,84.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,00904-6627-35,NDC,outpatient,15,ML,6.35,4.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-21,NDC,outpatient,15,ML,17.89,12.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-23,NDC,outpatient,15,ML,15.56,10.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,00054-8550-25,NDC,outpatient,1,UN,5.49,3.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-15,NDC,outpatient,1,UN,5.12,3.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-11,NDC,outpatient,1,UN,5.12,3.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-136367,CDM,S5000,HCPCS,250,RC,44567-0601-04,NDC,outpatient,10,ML,205.59,143.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,53329-0172-10,NDC,outpatient,71,GR,15.17,10.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,11701-0067-23,NDC,outpatient,57,GR,25.88,18.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70092-9054-05,NDC,outpatient,275,ML,111.55,78.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,71506-0015-58,NDC,outpatient,275,ML,93.39,65.373,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70004-0923-59,NDC,outpatient,275,ML,170.02,119.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,99999-0001-85,NDC,outpatient,275,ML,59.61,41.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-00,NDC,outpatient,15,ML,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-15,NDC,outpatient,15,ML,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,76154-0818-05,NDC,outpatient,125,ML,82.75,57.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,99999-0003-40,NDC,outpatient,125,ML,51.6,36.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1068-07,NDC,outpatient,500,ML,106.3,74.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1552-07,NDC,outpatient,500,ML,97.53,68.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LINACLOTIDE 72 MCG ORAL CAPS,RX-138008,CDM,S5000,HCPCS,259,RC,00456-1203-30,NDC,outpatient,1,UN,74.11,51.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,57896-0145-14,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,00536-1263-28,NDC,outpatient,28,GR,4.99,3.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,58980-0011-10,NDC,outpatient,28.35,GR,10.1,7.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,99999-0002-01,NDC,outpatient,540,ML,36.84,25.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,71506-0019-59,NDC,outpatient,540,ML,128.46,89.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,99999-0002-00,NDC,outpatient,535,ML,35.39,24.773,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,71506-0017-59,NDC,outpatient,535,ML,119.16,83.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZOCAINE 20 % MT AERO,RX-138339,CDM,S5000,HCPCS,259,RC,00283-0679-02,NDC,outpatient,57,GR,120.74,84.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP,RX-138354,CDM,S5000,HCPCS,250,RC,10122-0510-01,NDC,outpatient,1.5,ML,1807.78,1265.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,RX-138355,CDM,S5000,HCPCS,250,RC,10122-0510-03,NDC,outpatient,3,ML,2153.49,1507.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00115-5211-16,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-11,NDC,outpatient,1,UN,12.93,9.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00009-0450-03,NDC,outpatient,1,UN,9.24,6.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,59762-0450-01,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-21,NDC,outpatient,1,UN,12.93,9.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1130-36,NDC,outpatient,100,ML,83.73,58.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1380-36,NDC,outpatient,100,ML,69.27,48.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,99999-0003-24,NDC,outpatient,100,ML,48.85,34.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,00310-6205-30,NDC,outpatient,1,UN,54.15,37.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,66993-0456-30,NDC,outpatient,1,UN,54.61,38.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,66993-0457-30,NDC,outpatient,1,UN,57.77,40.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,00310-6210-39,NDC,outpatient,1,UN,54.15,37.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,00536-5090-08,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,24208-0387-62,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-00,NDC,outpatient,1.14,ML,5813.71,4069.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARISOPRODOL 350 MG ORAL TABS,RX-1395,CDM,S5000,HCPCS,259,RC,50228-0109-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,00904-7007-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,51672-4130-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,00904-7008-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,51672-4131-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CARBONATE ANTACID 1250 MG/5ML ORAL SUSP,RX-140541,CDM,S5000,HCPCS,259,RC,00121-4766-05,NDC,outpatient,5,ML,9.19,6.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-01,NDC,outpatient,1,UN,13.61,9.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-20,NDC,outpatient,1,UN,13.61,9.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-01,NDC,outpatient,1,UN,16,11.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-20,NDC,outpatient,1,UN,16,11.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,S5000,HCPCS,259,RC,45802-0465-64,NDC,outpatient,120,ML,53.4,37.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,RX-141345,CDM,S5000,HCPCS,259,RC,59310-0302-40,NDC,outpatient,10.6,GR,878.5,614.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,RX-141346,CDM,S5000,HCPCS,259,RC,59310-0304-80,NDC,outpatient,10.6,GR,1176.28,823.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG ORAL TABS,RX-142007,CDM,S5000,HCPCS,259,RC,61958-2501-01,NDC,outpatient,1,UN,572.84,400.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,99999-0002-78,NDC,outpatient,5,ML,12.62,8.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,59762-5030-01,NDC,outpatient,35,ML,84.73,59.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,16714-0696-01,NDC,outpatient,35,ML,43.77,30.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,10006-0700-13,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,68585-0005-75,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,57896-0635-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,71740-0112-30,NDC,outpatient,0.25,ML,14.74,10.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,99999-0003-49,NDC,outpatient,1,ML,58.94,41.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG ORAL TABS,RX-143657,CDM,S5000,HCPCS,259,RC,59676-0800-30,NDC,outpatient,1,UN,678.69,475.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PIMAVANSERIN TARTRATE 34 MG ORAL CAPS,RX-143683,CDM,S5000,HCPCS,259,RC,63090-0340-30,NDC,outpatient,1,UN,740.93,518.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-01,NDC,outpatient,1,UN,69.73,48.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-39,NDC,outpatient,1,UN,69.73,48.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,52817-0610-04,NDC,outpatient,1,UN,36.6,25.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-16,NDC,outpatient,1,UN,58.96,41.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-99,NDC,outpatient,1,UN,58.96,41.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-04,NDC,outpatient,1,UN,89.34,62.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-01,NDC,outpatient,1,UN,43.76,30.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-54,NDC,outpatient,1,UN,89.34,62.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-04,NDC,outpatient,1,UN,43.76,30.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,82089-0102-34,NDC,outpatient,1,UN,502.38,351.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-04,NDC,outpatient,1,UN,122.13,85.491,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-54,NDC,outpatient,1,UN,122.13,85.491,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,42571-0141-26,NDC,outpatient,10,ML,151.26,105.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,24208-0485-10,NDC,outpatient,10,ML,36.09,25.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,61314-0019-10,NDC,outpatient,10,ML,71.78,50.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-93,NDC,outpatient,3,ML,93.63,65.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-32,NDC,outpatient,3,ML,93.63,65.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-15,NDC,outpatient,1,UN,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-11,NDC,outpatient,1,UN,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-11,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-15,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-02,NDC,outpatient,5,ML,2091.2,1463.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-15,NDC,outpatient,5,ML,2091.2,1463.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,69238-1731-02,NDC,outpatient,473,ML,2201.68,1541.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,99999-0002-40,NDC,outpatient,5,ML,47,32.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL ER 180 MG ORAL TBCR,RX-14626,CDM,S5000,HCPCS,259,RC,75834-0158-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-11,NDC,outpatient,1,UN,9.29,6.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-21,NDC,outpatient,1,UN,9.29,6.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00904-7179-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,29300-0355-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00093-0058-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETIC ACID 5 % SOLN,RX-14702,CDM,S5000,HCPCS,259,RC,99999-0000-92,NDC,outpatient,60,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,00904-7163-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLYBURIDE MICRONIZED 1.5 MG ORAL TABS,RX-14777,CDM,S5000,HCPCS,259,RC,00093-8034-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147794,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-03,NDC,outpatient,100,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-01,NDC,outpatient,100,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-30,NDC,outpatient,1,UN,14.17,9.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-01,NDC,outpatient,1,UN,14.17,9.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-11,NDC,outpatient,1,UN,2.93,2.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-15,NDC,outpatient,1,UN,2.93,2.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIZANIDINE HCL 4 MG ORAL TABS,RX-14793,CDM,S5000,HCPCS,259,RC,00904-6418-61,NDC,outpatient,1,UN,1.85,1.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-88,NDC,outpatient,1,UN,22.99,16.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-30,NDC,outpatient,1,UN,20.73,14.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-77,NDC,outpatient,1,UN,20.73,14.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-32,NDC,outpatient,1,UN,22.99,16.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,64764-0544-11,NDC,outpatient,1,UN,56.9,39.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-11,NDC,outpatient,1,UN,1.75,1.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-01,NDC,outpatient,1,UN,1.75,1.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-11,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,00904-7048-61,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-15,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-99,NDC,outpatient,1,UN,214.58,150.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,69097-0579-67,NDC,outpatient,1,UN,204.35,143.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-94,NDC,outpatient,1,UN,214.58,150.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,70748-0299-01,NDC,outpatient,210,ML,615.84,431.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,99999-0004-54,NDC,outpatient,5,ML,14.67,10.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-01,NDC,outpatient,30,ML,8.02,5.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-03,NDC,outpatient,30,ML,8.02,5.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MOEXIPRIL HCL 7.5 MG ORAL TABS,RX-15025,CDM,S5000,HCPCS,259,RC,68462-0209-01,NDC,outpatient,1,UN,3.46,2.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0140-03,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,00904-2085-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0101-44,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORT-PRAMOXINE (PERIANAL) 2.5-1 % EX CREA,RX-150325,CDM,S5000,HCPCS,259,RC,45802-0472-64,NDC,outpatient,30,GR,583,408.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,51552-0051-06,NDC,outpatient,500,ML,97.9,68.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,99999-0001-49,NDC,outpatient,60,ML,11.75,8.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-59,NDC,outpatient,15,ML,10.55,7.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-62,NDC,outpatient,15,ML,10.55,7.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-01,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-20,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-11,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-01,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,00087-0405-01,NDC,outpatient,0.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,99999-0001-69,NDC,outpatient,0.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TACROLIMUS ER 1 MG ORAL TB24,RX-151676,CDM,S5000,HCPCS,259,RC,68992-3010-03,NDC,outpatient,1,UN,3.04,2.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TACROLIMUS ER 0.75 MG ORAL TB24,RX-151678,CDM,S5000,HCPCS,259,RC,68992-3075-03,NDC,outpatient,1,UN,2.28,1.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TACROLIMUS ER 4 MG ORAL TB24,RX-151679,CDM,S5000,HCPCS,259,RC,68992-3040-03,NDC,outpatient,1,UN,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-59,NDC,outpatient,10,ML,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,99999-0002-42,NDC,outpatient,10,ML,1.6,1.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-10,NDC,outpatient,10,ML,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-08,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-10,NDC,outpatient,10,ML,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-01,NDC,outpatient,1,ML,93.05,65.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-25,NDC,outpatient,1,ML,93.05,65.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHACHOLINE CHLORIDE IN KIT,RX-151916,CDM,S5000,HCPCS,259,RC,69374-0542-06,NDC,outpatient,18,ML,600.75,420.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,00536-1294-97,NDC,outpatient,100,GR,33.38,23.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,43598-0977-10,NDC,outpatient,100,GR,59.19,41.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,69097-0524-44,NDC,outpatient,100,GR,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUMATRIPTAN SUCCINATE 25 MG ORAL TABS,RX-15327,CDM,S5000,HCPCS,259,RC,65862-0146-36,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-11,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,16571-0202-10,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,61442-0102-01,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,00228-2550-11,NDC,outpatient,1,UN,1.63,1.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-01,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 75 MG ORAL TBEC,RX-15341,CDM,S5000,HCPCS,259,RC,16571-0201-06,NDC,outpatient,1,UN,1.46,1.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,00225-0525-47,NDC,outpatient,14.1,GR,10.92,7.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,05928-0000-99,NDC,outpatient,28.4,GR,22.75,15.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIMANTADINE HCL 100 MG ORAL TABS,RX-15440,CDM,S5000,HCPCS,259,RC,00115-1911-01,NDC,outpatient,1,UN,10.21,7.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHERRY ORAL SYRP,RX-1562,CDM,S5000,HCPCS,259,RC,00395-2662-16,NDC,outpatient,473,ML,78.58,55.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-09,NDC,outpatient,250,ML,59.39,41.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-13,NDC,outpatient,500,ML,73.85,51.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMANTADINE HCL 50 MG/5ML ORAL SOLN,RX-156382,CDM,S5000,HCPCS,259,RC,00121-0646-10,NDC,outpatient,10,ML,13.67,9.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALENDRONATE SODIUM 10 MG ORAL TABS,RX-15661,CDM,S5000,HCPCS,259,RC,16714-0631-01,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156724,CDM,S5000,HCPCS,250,RC,60267-0705-50,NDC,outpatient,50,ML,431.65,302.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN,RX-156740,CDM,S5000,HCPCS,250,RC,24571-0108-06,NDC,outpatient,5000,ML,294.88,206.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN,RX-156741,CDM,S5000,HCPCS,250,RC,24571-0105-06,NDC,outpatient,5000,ML,294.88,206.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN,RX-156742,CDM,S5000,HCPCS,250,RC,24571-0102-06,NDC,outpatient,5000,ML,294.88,206.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L EC SOLN,RX-156743,CDM,S5000,HCPCS,250,RC,24571-0103-06,NDC,outpatient,5000,ML,325.06,227.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,60505-0159-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,00093-1060-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,49884-0161-11,NDC,outpatient,3.7,ML,207.33,145.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,60505-0823-06,NDC,outpatient,3.7,ML,230.15,161.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARVEDILOL 6.25 MG ORAL TABS,RX-15747,CDM,S5000,HCPCS,259,RC,00904-6301-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,00904-6302-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,68382-0094-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,99999-0002-81,NDC,outpatient,6.25,ML,21.03,14.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,00093-2026-23,NDC,outpatient,18.75,ML,62.17,43.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,59762-3120-01,NDC,outpatient,18.75,ML,76.85,53.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DARUNAVIR 800 MG ORAL TABS,RX-158170,CDM,S5000,HCPCS,259,RC,59676-0566-30,NDC,outpatient,1,UN,310.53,217.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00002-7533-01,NDC,outpatient,3,ML,80.06,56.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5924-10,NDC,outpatient,10,ML,322.63,225.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5926-05,NDC,outpatient,3,ML,50.03,35.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,00904-6583-04,NDC,outpatient,1,UN,21.27,14.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,64380-0710-03,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LAMIVUDINE 10 MG/ML ORAL SOLN,RX-15881,CDM,S5000,HCPCS,259,RC,54838-0566-70,NDC,outpatient,15,ML,23.1,16.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACARBOSE 50 MG ORAL TABS,RX-15895,CDM,S5000,HCPCS,259,RC,64380-0759-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,S5000,HCPCS,259,RC,00436-0936-16,NDC,outpatient,473,ML,52.63,36.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-02,NDC,outpatient,1,UN,571.55,400.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-20,NDC,outpatient,1,UN,3544.84,2481.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-03,NDC,outpatient,1,UN,571.55,400.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-30,NDC,outpatient,1,UN,3544.84,2481.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,99999-0002-10,NDC,outpatient,10,ML,27.28,19.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,00406-0527-10,NDC,outpatient,0.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-160113,CDM,S5000,HCPCS,259,RC,00046-0872-21,NDC,outpatient,30,GR,1850.58,1295.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,S5000,HCPCS,259,RC,16714-0763-01,NDC,outpatient,60,GR,327.35,229.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-11,NDC,outpatient,1,UN,3.58,2.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-51,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,80681-0100-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-11,NDC,outpatient,1,UN,7.9,5.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,23155-0490-01,NDC,outpatient,1,UN,1.27,0.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-21,NDC,outpatient,1,UN,7.9,5.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLENE BLUE 1 % IV SOLN,RX-160649,CDM,S5000,HCPCS,250,RC,54288-0147-01,NDC,outpatient,10,ML,616.77,431.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,00574-0520-74,NDC,outpatient,120,ML,51.8,36.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,66689-0203-04,NDC,outpatient,120,ML,73.16,51.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,24208-0398-30,NDC,outpatient,30,ML,45.66,31.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,00054-0045-44,NDC,outpatient,30,ML,160.2,112.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CARB-CHOLECALCIFEROL 600-5 MG-MCG ORAL TABS,RX-160700,CDM,S5000,HCPCS,259,RC,80681-0138-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,00054-0046-41,NDC,outpatient,15,ML,147.99,103.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,60505-0827-01,NDC,outpatient,15,ML,69.49,48.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMCICLOVIR 250 MG ORAL TABS,RX-16081,CDM,S5000,HCPCS,259,RC,60505-3246-03,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,00536-3223-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-03,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RILUZOLE 50 MG ORAL TABS,RX-16124,CDM,S5000,HCPCS,259,RC,67877-0286-60,NDC,outpatient,1,UN,2.96,2.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,99999-0002-71,NDC,outpatient,1,ML,19.3,13.51,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,63304-0241-59,NDC,outpatient,1,ML,19.3,13.51,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,00054-3120-41,NDC,outpatient,1,ML,24.45,17.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-20,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,00555-0159-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-01,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-01,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-20,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EUCERIN ORIGINAL HEALING EX CREA,RX-162713,CDM,S5000,HCPCS,259,RC,72140-0038-68,NDC,outpatient,57,GR,20.04,14.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-01,NDC,outpatient,1,UN,2.06,1.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-11,NDC,outpatient,1,UN,2.06,1.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,55111-0321-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPH-SHARK LIV OIL-MO-PET 0.25-3-14-71.9 % RE OINT,RX-16462,CDM,S5000,HCPCS,259,RC,00573-2871-93,NDC,outpatient,28,GR,25.8,18.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,00904-7129-61,NDC,outpatient,1,UN,10.41,7.287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-15,NDC,outpatient,1,UN,4.66,3.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-11,NDC,outpatient,1,UN,4.66,3.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,69238-1060-01,NDC,outpatient,1,UN,6.98,4.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,00904-7132-61,NDC,outpatient,1,UN,20.86,14.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-15,NDC,outpatient,1,UN,7.19,5.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,69238-1056-01,NDC,outpatient,1,UN,2.88,2.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-11,NDC,outpatient,1,UN,7.19,5.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00536-1252-40,NDC,outpatient,5,ML,30.09,21.063,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,72485-0617-10,NDC,outpatient,5,ML,28.93,20.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00065-4011-05,NDC,outpatient,5,ML,42.77,29.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-01,NDC,outpatient,1,UN,7.86,5.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-20,NDC,outpatient,1,UN,7.86,5.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-01,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-11,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,63739-0888-10,NDC,outpatient,1,UN,2.7,1.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERROUS SULFATE ER 45 MG ORAL TBCR,RX-167735,CDM,S5000,HCPCS,259,RC,10006-0730-13,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,S5000,HCPCS,250,RC,00942-0641-04,NDC,outpatient,1000,ML,60.15,42.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,20555-0036-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYOSCYAMINE SULFATE ER 0.375 MG ORAL TB12,RX-17010,CDM,S5000,HCPCS,259,RC,51525-0115-01,NDC,outpatient,1,UN,1.16,0.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANDOLAPRIL 1 MG ORAL TABS,RX-17017,CDM,S5000,HCPCS,259,RC,68180-0566-01,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SELEGILINE HCL 5 MG ORAL CAPS,RX-17280,CDM,S5000,HCPCS,259,RC,60505-0055-01,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0452-31,NDC,outpatient,50,GR,20.25,14.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,61924-0184-04,NDC,outpatient,106,GR,13.68,9.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0031-47,NDC,outpatient,396,GR,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,65162-0673-84,NDC,outpatient,0.25,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,27808-0002-01,NDC,outpatient,0.25,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,99999-0003-81,NDC,outpatient,1,ML,4.12,2.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AZITHROMYCIN 600 MG ORAL TABS,RX-17387,CDM,S5000,HCPCS,259,RC,62332-0253-30,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN HCL 150 MG ORAL CAPS,RX-1740,CDM,S5000,HCPCS,259,RC,00904-5959-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEVIRAPINE 200 MG ORAL TABS,RX-17403,CDM,S5000,HCPCS,259,RC,31722-0505-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,45802-0562-02,NDC,outpatient,60,ML,48.6,34.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,00168-0201-60,NDC,outpatient,60,ML,139.11,97.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,00904-6519-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,RX-17524,CDM,S5000,HCPCS,250,RC,59584-0138-01,NDC,outpatient,0.1,ML,121.71,85.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-01,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-11,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABS,RX-1759,CDM,S5000,HCPCS,259,RC,13107-0319-01,NDC,outpatient,1,UN,4.43,3.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,45802-0434-11,NDC,outpatient,30,GR,10.42,7.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,51672-2002-02,NDC,outpatient,30,GR,6.01,4.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,S5000,HCPCS,259,RC,51672-1260-03,NDC,outpatient,30,ML,97.86,68.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,S5000,HCPCS,259,RC,51672-2003-06,NDC,outpatient,45,GR,11.82,8.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,61314-0143-05,NDC,outpatient,5,ML,13.04,9.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,24208-0411-05,NDC,outpatient,5,ML,61.95,43.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,71921-0185-05,NDC,outpatient,5,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,70069-0231-01,NDC,outpatient,5,ML,7.26,5.082,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
B COMPLEX ORAL CAPS,RX-17882,CDM,S5000,HCPCS,259,RC,54629-0560-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 5 MG ORAL TABS,RX-17936,CDM,S5000,HCPCS,259,RC,00904-6377-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXAMETHASONE 1 MG/ML ORAL CONC,RX-17946,CDM,S5000,HCPCS,259,RC,00054-3176-44,NDC,outpatient,30,ML,90.92,63.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-21,NDC,outpatient,1,UN,10.83,7.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-11,NDC,outpatient,1,UN,10.83,7.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,S5000,HCPCS,259,RC,45802-0513-77,NDC,outpatient,140,GR,35.52,24.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CODEINE SULFATE 15 MG ORAL TABS,RX-1801,CDM,S5000,HCPCS,259,RC,00054-0243-24,NDC,outpatient,1,UN,2.94,2.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNA 8.6 MG ORAL TABS,RX-18138,CDM,S5000,HCPCS,259,RC,00904-7252-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-01,NDC,outpatient,1,UN,13.56,9.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,65162-0710-09,NDC,outpatient,1,UN,2.83,1.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-03,NDC,outpatient,1,UN,13.56,9.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISOPROLOL FUMARATE 5 MG ORAL TABS,RX-18288,CDM,S5000,HCPCS,259,RC,29300-0126-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,10135-0742-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,29300-0189-01,NDC,outpatient,1,UN,2.16,1.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG ORAL TABS,RX-18290,CDM,S5000,HCPCS,259,RC,29300-0188-01,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,29300-0187-01,NDC,outpatient,1,UN,2.03,1.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,68462-0878-30,NDC,outpatient,1,UN,1.61,1.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-15,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-11,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-25,NDC,outpatient,1,UN,1.1,0.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-11,NDC,outpatient,1,UN,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-29,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-15,NDC,outpatient,1,UN,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-01,NDC,outpatient,1,UN,1.28,0.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-11,NDC,outpatient,1,UN,1.28,0.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-15,NDC,outpatient,1,UN,1.64,1.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,31722-0532-01,NDC,outpatient,1,UN,2.32,1.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-11,NDC,outpatient,1,UN,1.64,1.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,00904-6667-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,63739-0904-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,45963-0556-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,63739-0903-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,00904-6666-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,16714-0662-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,63739-0902-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,00904-6665-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 2 MG ORAL TABS,RX-18311,CDM,S5000,HCPCS,259,RC,00904-7363-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,00904-7362-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,42291-0910-60,NDC,outpatient,1,UN,11.7,8.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-11,NDC,outpatient,1,UN,2.72,1.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-01,NDC,outpatient,1,UN,2.72,1.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-25,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-95,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-01,NDC,outpatient,1,UN,164.07,114.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-03,NDC,outpatient,1,UN,164.48,115.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-10,NDC,outpatient,1,UN,164.07,114.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-01,NDC,outpatient,1,UN,164.48,115.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARVEDILOL 3.125 MG ORAL TABS,RX-18551,CDM,S5000,HCPCS,259,RC,00904-6300-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,24208-0463-25,NDC,outpatient,2.5,ML,46.77,32.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,59762-0333-02,NDC,outpatient,2.5,ML,18.92,13.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,61314-0547-01,NDC,outpatient,2.5,ML,19.1,13.37,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,70069-0421-01,NDC,outpatient,2.5,ML,19.9,13.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DONEPEZIL HCL 5 MG ORAL TABS,RX-18786,CDM,S5000,HCPCS,259,RC,00904-6477-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,43598-0587-23,NDC,outpatient,2,ML,87.58,61.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,67457-0839-02,NDC,outpatient,2,ML,53.45,37.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,72485-0105-01,NDC,outpatient,2,ML,69.91,48.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOFLOXACIN 250 MG ORAL TABS,RX-18918,CDM,S5000,HCPCS,259,RC,00904-6351-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOFLOXACIN 500 MG ORAL TABS,RX-18919,CDM,S5000,HCPCS,259,RC,00904-6352-61,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-11,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-01,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-01,NDC,outpatient,1,UN,2.19,1.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-11,NDC,outpatient,1,UN,2.19,1.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATORVASTATIN CALCIUM 10 MG ORAL TABS,RX-19176,CDM,S5000,HCPCS,259,RC,00904-6290-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATORVASTATIN CALCIUM 20 MG ORAL TABS,RX-19178,CDM,S5000,HCPCS,259,RC,00904-6291-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,S5000,HCPCS,259,RC,60505-0833-05,NDC,outpatient,30,ML,24.97,17.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,59762-1005-01,NDC,outpatient,1,UN,22.17,15.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,23155-0823-73,NDC,outpatient,1,UN,8.36,5.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,50742-0118-08,NDC,outpatient,1,UN,13.91,9.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,S5000,HCPCS,259,RC,70756-0614-30,NDC,outpatient,5,ML,178,124.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZOCAINE 20 % MT GEL,RX-19691,CDM,S5000,HCPCS,259,RC,10310-0566-20,NDC,outpatient,11.9,GR,20.34,14.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,S5000,HCPCS,259,RC,00065-0023-15,NDC,outpatient,1.5,ML,66,46.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,00254-1010-19,NDC,outpatient,30,ML,1132.89,793.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,99999-0003-50,NDC,outpatient,1,ML,37.77,26.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,61314-0014-25,NDC,outpatient,2.5,ML,39.79,27.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,24208-0457-05,NDC,outpatient,5,ML,46.46,32.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,S5000,HCPCS,259,RC,11980-0228-05,NDC,outpatient,5,ML,692.51,484.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00009-0746-30,NDC,outpatient,1,ML,216.41,151.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00548-5400-00,NDC,outpatient,1,ML,75.65,52.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,00135-0199-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,49348-0541-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,60505-0560-00,NDC,outpatient,5,ML,32.22,22.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,64980-0515-05,NDC,outpatient,5,ML,58.61,41.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POVIDONE-IODINE 5 % OP SOLN,RX-19791,CDM,S5000,HCPCS,259,RC,00065-0411-30,NDC,outpatient,30,ML,45.26,31.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-POLYMYXIN-PRAMOXINE 1 % EX CREA,RX-19880,CDM,S5000,HCPCS,259,RC,12547-0407-40,NDC,outpatient,14.2,GR,19.03,13.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-11,NDC,outpatient,1,UN,1.26,0.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-01,NDC,outpatient,1,UN,1.26,0.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NELFINAVIR MESYLATE 250 MG ORAL TABS,RX-20032,CDM,S5000,HCPCS,259,RC,63010-0010-30,NDC,outpatient,1,UN,17.47,12.229,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESNA 400 MG ORAL TABS,RX-20077,CDM,S5000,HCPCS,259,RC,67108-3565-09,NDC,outpatient,1,UN,287.17,201.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-01,NDC,outpatient,2,ML,47.31,33.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-06,NDC,outpatient,15,ML,121.82,85.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-11,NDC,outpatient,1,UN,2.94,2.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-15,NDC,outpatient,1,UN,2.94,2.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-01,NDC,outpatient,10,ML,375.94,263.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-03,NDC,outpatient,10,ML,375.94,263.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,00172-5241-60,NDC,outpatient,1,UN,3.43,2.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,13668-0453-01,NDC,outpatient,1,UN,2.97,2.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-10,NDC,outpatient,10,ML,25.46,17.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,55150-0221-10,NDC,outpatient,10,ML,12.44,8.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-01,NDC,outpatient,20,ML,27.51,19.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-10,NDC,outpatient,20,ML,27.51,19.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-01,NDC,outpatient,10,ML,25.46,17.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-01,NDC,outpatient,10,ML,13.73,9.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-10,NDC,outpatient,10,ML,13.73,9.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX LIQD,RX-20781,CDM,S5000,HCPCS,259,RC,49348-0443-34,NDC,outpatient,118,ML,21.53,15.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIGLITOL 25 MG ORAL TABS,RX-20799,CDM,S5000,HCPCS,259,RC,69367-0303-01,NDC,outpatient,1,UN,7.35,5.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-10,NDC,outpatient,5,ML,20.56,14.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-05,NDC,outpatient,5,ML,9.31,6.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-05,NDC,outpatient,5,ML,10.16,7.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-41,NDC,outpatient,5,ML,10.16,7.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-01,NDC,outpatient,5,ML,20.56,14.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-01,NDC,outpatient,5,ML,9.31,6.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-01,NDC,outpatient,1,UN,3.5,2.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-11,NDC,outpatient,1,UN,3.5,2.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,65862-0641-63,NDC,outpatient,1,UN,1.45,1.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,54482-0147-01,NDC,outpatient,5,ML,99.51,69.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-01,NDC,outpatient,5,ML,94.7,66.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-10,NDC,outpatient,5,ML,94.7,66.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 2.5 MG ORAL TABS,RX-21057,CDM,S5000,HCPCS,259,RC,00904-6283-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-01,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-11,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,62756-0184-88,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CITALOPRAM HYDROBROMIDE 20 MG ORAL TABS,RX-21062,CDM,S5000,HCPCS,259,RC,00904-6085-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG ORAL TABS,RX-21284,CDM,S5000,HCPCS,259,RC,42806-0339-01,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-11,NDC,outpatient,1,UN,3.34,2.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-21,NDC,outpatient,1,UN,3.34,2.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG ORAL TABS,RX-21289,CDM,S5000,HCPCS,259,RC,68462-0334-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG ORAL TABS,RX-21290,CDM,S5000,HCPCS,259,RC,00904-6704-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,00904-5448-61,NDC,outpatient,1,UN,1.11,0.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,60505-0033-06,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAPSONE 100 MG ORAL TABS,RX-2131,CDM,S5000,HCPCS,259,RC,70954-0136-10,NDC,outpatient,1,UN,5.05,3.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAPSONE 25 MG ORAL TABS,RX-2132,CDM,S5000,HCPCS,259,RC,70954-0135-10,NDC,outpatient,1,UN,4.35,3.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,00078-0249-15,NDC,outpatient,1,UN,108.93,76.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,59651-0180-30,NDC,outpatient,1,UN,1.55,1.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR,RX-21672,CDM,S5000,HCPCS,250,RC,24338-0050-08,NDC,outpatient,8,UN,110831.48,77582.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROPINIROLE HCL 0.25 MG ORAL TABS,RX-21688,CDM,S5000,HCPCS,259,RC,00904-6373-61,NDC,outpatient,1,UN,1.51,1.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROPINIROLE HCL 1 MG ORAL TABS,RX-21689,CDM,S5000,HCPCS,259,RC,00904-6374-61,NDC,outpatient,1,UN,1.76,1.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-15,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-11,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,00904-6638-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
QUETIAPINE FUMARATE 100 MG ORAL TABS,RX-21824,CDM,S5000,HCPCS,259,RC,00904-6640-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TIAGABINE HCL 4 MG ORAL TABS,RX-21827,CDM,S5000,HCPCS,259,RC,62756-0224-83,NDC,outpatient,1,UN,16.11,11.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,31722-0730-90,NDC,outpatient,1,UN,1.91,1.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,33342-0048-10,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOPIDOGREL BISULFATE 75 MG ORAL TABS,RX-22142,CDM,S5000,HCPCS,259,RC,00904-6294-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-21,NDC,outpatient,1,UN,23.4,16.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-11,NDC,outpatient,1,UN,23.4,16.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-03,NDC,outpatient,1,UN,40.12,28.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-13,NDC,outpatient,1,UN,40.12,28.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-04,NDC,outpatient,5,ML,27.71,19.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-44,NDC,outpatient,5,ML,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-56,NDC,outpatient,5,ML,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-56,NDC,outpatient,5,ML,27.71,19.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,51672-1370-01,NDC,outpatient,15,GR,62.62,43.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,68462-0564-17,NDC,outpatient,15,GR,861.28,602.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,70756-0609-15,NDC,outpatient,5,ML,31.29,21.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,24208-0410-05,NDC,outpatient,5,ML,214.49,150.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-25,NDC,outpatient,1,UN,1.55,1.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,00904-5224-52,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-50,NDC,outpatient,1,UN,1.55,1.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-06,NDC,outpatient,1,UN,1.19,0.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-61,NDC,outpatient,1,UN,1.44,1.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-11,NDC,outpatient,1,UN,2.8,1.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-15,NDC,outpatient,1,UN,2.8,1.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-40,NDC,outpatient,20,ML,60.61,42.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,99999-0002-45,NDC,outpatient,20,ML,22.52,15.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-20,NDC,outpatient,20,ML,60.61,42.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
REPAGLINIDE 2 MG ORAL TABS,RX-22585,CDM,S5000,HCPCS,259,RC,65862-0672-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
REPAGLINIDE 1 MG ORAL TABS,RX-22586,CDM,S5000,HCPCS,259,RC,65862-0671-01,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,99999-0002-34,NDC,outpatient,15,ML,3.14,2.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,60258-0003-16,NDC,outpatient,10,ML,5.88,4.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,00121-0676-16,NDC,outpatient,15,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,00904-6890-04,NDC,outpatient,1,UN,10.99,7.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-11,NDC,outpatient,1,UN,6.99,4.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-21,NDC,outpatient,1,UN,6.99,4.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,68462-0473-01,NDC,outpatient,1,UN,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESIPRAMINE HCL 25 MG ORAL TABS,RX-2286,CDM,S5000,HCPCS,259,RC,50742-0113-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,99999-0001-34,NDC,outpatient,10,ML,72.98,51.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,70954-0319-10,NDC,outpatient,5,ML,32.69,22.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,24208-0486-10,NDC,outpatient,10,ML,45.62,31.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,65862-0946-01,NDC,outpatient,10,ML,89,62.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,71921-0226-10,NDC,outpatient,10,ML,45.39,31.773,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,82584-0605-10,NDC,outpatient,10,ML,996.05,697.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,70069-0051-01,NDC,outpatient,10,ML,38.99,27.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,42571-0160-30,NDC,outpatient,1,UN,9.65,6.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,00781-1874-31,NDC,outpatient,1,UN,6.58,4.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,00004-1101-50,NDC,outpatient,1,UN,195.05,136.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,16729-0073-29,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISEDRONATE SODIUM 30 MG ORAL TABS,RX-23015,CDM,S5000,HCPCS,259,RC,00093-3100-56,NDC,outpatient,1,UN,220.55,154.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,00536-1268-12,NDC,outpatient,222,ML,16.8,11.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,46122-0573-10,NDC,outpatient,222,ML,11.13,7.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINISOL SF 15 % IV SOLN,RX-23068,CDM,S5000,HCPCS,250,RC,00338-0502-06,NDC,outpatient,2000,ML,211.8,148.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1123-04,NDC,outpatient,2000,ML,211.8,148.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1147-03,NDC,outpatient,1000,ML,122.8,85.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXAMETHASONE 0.5 MG ORAL TABS,RX-2322,CDM,S5000,HCPCS,259,RC,00054-8179-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,33342-0114-07,NDC,outpatient,1,UN,5.64,3.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,62332-0341-90,NDC,outpatient,1,UN,4.08,2.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CANDESARTAN CILEXETIL 16 MG ORAL TABS,RX-23231,CDM,S5000,HCPCS,259,RC,33342-0116-07,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXAMETHASONE 1 MG ORAL TABS,RX-2324,CDM,S5000,HCPCS,259,RC,00054-8174-25,NDC,outpatient,1,UN,1.46,1.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,00054-8175-25,NDC,outpatient,1,UN,4.2,2.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-51,NDC,outpatient,1,UN,4.47,3.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-80,NDC,outpatient,1,UN,4.47,3.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXAMETHASONE 6 MG ORAL TABS,RX-2328,CDM,S5000,HCPCS,259,RC,00054-8183-25,NDC,outpatient,1,UN,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,S5000,HCPCS,259,RC,24208-0720-02,NDC,outpatient,5,ML,228.82,160.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-05,NDC,outpatient,5,GR,12.51,8.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-06,NDC,outpatient,5,GR,12.51,8.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,39328-0024-30,NDC,outpatient,30,GR,40.32,28.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-02,NDC,outpatient,250,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 20 % IV SOLN,RX-2359,CDM,S5000,HCPCS,250,RC,00990-7935-19,NDC,outpatient,500,ML,62.73,43.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,S5000,HCPCS,250,RC,00409-1775-10,NDC,outpatient,10,ML,57.77,40.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-34,NDC,outpatient,50,ML,59.41,41.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-16,NDC,outpatient,50,ML,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-66,NDC,outpatient,50,ML,58.08,40.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,76329-3302-01,NDC,outpatient,50,ML,66.31,46.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-02,NDC,outpatient,50,ML,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-16,NDC,outpatient,50,ML,31.82,22.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-64,NDC,outpatient,50,ML,59.41,41.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69374-0953-50,NDC,outpatient,50,ML,66.75,46.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69623-0201-39,NDC,outpatient,50,ML,93.45,65.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EFAVIRENZ 200 MG ORAL CAPS,RX-23900,CDM,S5000,HCPCS,259,RC,64980-0407-09,NDC,outpatient,1,UN,33.64,23.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,00172-3925-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MICONAZOLE NITRATE 4 % VA CREA,RX-24050,CDM,S5000,HCPCS,259,RC,63736-0442-01,NDC,outpatient,15,GR,44.73,31.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,00093-3123-01,NDC,outpatient,1,UN,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,59651-0565-01,NDC,outpatient,1,UN,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-59,NDC,outpatient,5,ML,21.65,15.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-62,NDC,outpatient,5,ML,21.65,15.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-11,NDC,outpatient,1,UN,1.75,1.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-01,NDC,outpatient,1,UN,1.75,1.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-11,NDC,outpatient,1,UN,1.8,1.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-01,NDC,outpatient,1,UN,1.8,1.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,00536-1248-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,63739-0432-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOSORBIDE MONONITRATE ER 60 MG ORAL TAB,RX-24268,CDM,S5000,HCPCS,259,RC,00904-6450-61,NDC,outpatient,1,UN,1.31,0.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TELMISARTAN 40 MG ORAL TABS,RX-24335,CDM,S5000,HCPCS,259,RC,00597-0040-37,NDC,outpatient,1,UN,19.23,13.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,S5000,HCPCS,259,RC,51672-3007-01,NDC,outpatient,10,ML,303.14,212.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,00378-4105-91,NDC,outpatient,1,UN,13.01,9.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-11,NDC,outpatient,1,UN,26.71,18.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-21,NDC,outpatient,1,UN,26.71,18.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIGOXIN 125 MCG ORAL TABS,RX-2444,CDM,S5000,HCPCS,259,RC,00904-5921-61,NDC,outpatient,1,UN,3.14,2.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-04,NDC,outpatient,1,UN,7.7,5.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-01,NDC,outpatient,1,UN,4.79,3.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-11,NDC,outpatient,1,UN,4.79,3.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,63739-0548-33,NDC,outpatient,1,UN,5.24,3.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-61,NDC,outpatient,1,UN,5.08,3.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-11,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-15,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-11,NDC,outpatient,1,UN,3.16,2.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,00904-6502-61,NDC,outpatient,1,UN,3.56,2.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-01,NDC,outpatient,1,UN,3.16,2.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,00904-6503-61,NDC,outpatient,1,UN,5.49,3.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,60505-3849-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOSORBIDE MONONITRATE ER 30 MG ORAL TB24,RX-24521,CDM,S5000,HCPCS,259,RC,00904-6449-61,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,00904-6791-04,NDC,outpatient,1,UN,21.38,14.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-12,NDC,outpatient,1,UN,25.83,18.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-11,NDC,outpatient,1,UN,25.83,18.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-11,NDC,outpatient,1,UN,21.38,14.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-21,NDC,outpatient,1,UN,21.38,14.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,S5000,HCPCS,259,RC,00574-7040-12,NDC,outpatient,1,UN,104.53,73.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,00093-0318-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-11,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-01,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIMENHYDRINATE 50 MG ORAL TABS,RX-2485,CDM,S5000,HCPCS,259,RC,00904-2051-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TACROLIMUS 0.5 MG ORAL CAPS,RX-24914,CDM,S5000,HCPCS,259,RC,00904-6623-61,NDC,outpatient,1,UN,2.82,1.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-45,NDC,outpatient,3,ML,7.12,4.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-11,NDC,outpatient,3,ML,5.32,3.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-56,NDC,outpatient,3,ML,7.12,4.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-01,NDC,outpatient,3,ML,5.32,3.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-01,NDC,outpatient,3,ML,5.47,3.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-11,NDC,outpatient,3,ML,5.47,3.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-55,NDC,outpatient,3,ML,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-60,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-31,NDC,outpatient,3,ML,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-49,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-52,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-79,NDC,outpatient,3,ML,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00487-9501-01,NDC,outpatient,3,ML,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-48,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-01,NDC,outpatient,3,ML,1.18,0.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-83,NDC,outpatient,3,ML,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,66689-0307-08,NDC,outpatient,160,ML,1111.44,778.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,99999-0002-21,NDC,outpatient,2.5,ML,69.2,48.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIPHENHYDRAMINE HCL 25 MG ORAL CAPS,RX-2509,CDM,S5000,HCPCS,259,RC,00904-7237-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-00,NDC,outpatient,5,ML,15.4,10.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-05,NDC,outpatient,5,ML,15.4,10.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,65862-0076-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,62135-0308-01,NDC,outpatient,1,UN,12.1,8.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,00143-9927-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,00406-1236-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,69315-0910-01,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,70752-0102-12,NDC,outpatient,5,ML,1.91,1.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,99999-0003-98,NDC,outpatient,5,ML,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,00472-0825-16,NDC,outpatient,5,ML,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIPYRIDAMOLE 25 MG ORAL TABS,RX-2528,CDM,S5000,HCPCS,259,RC,64980-0133-01,NDC,outpatient,1,UN,5.27,3.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-25,NDC,outpatient,1,UN,27.72,19.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-95,NDC,outpatient,1,UN,27.72,19.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DISOPYRAMIDE PHOSPHATE 100 MG ORAL CAPS,RX-2535,CDM,S5000,HCPCS,259,RC,00093-3127-01,NDC,outpatient,1,UN,5.28,3.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DISULFIRAM 250 MG ORAL TABS,RX-2540,CDM,S5000,HCPCS,259,RC,47781-0607-30,NDC,outpatient,1,UN,7.69,5.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-10,NDC,outpatient,1,UN,3.43,2.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-81,NDC,outpatient,1,UN,3.67,2.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-86,NDC,outpatient,1,UN,3.67,2.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-17,NDC,outpatient,1,UN,3.43,2.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-21,NDC,outpatient,1,UN,3.46,2.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-11,NDC,outpatient,1,UN,3.46,2.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68382-0112-14,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 0.5 MG ORAL TABS,RX-25520,CDM,S5000,HCPCS,259,RC,00904-7361-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-11,NDC,outpatient,1,UN,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-01,NDC,outpatient,1,UN,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-61,NDC,outpatient,1,UN,1.16,0.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-11,NDC,outpatient,1,UN,1.16,0.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,00904-6861-90,NDC,outpatient,1,UN,1.2,0.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7183-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-80,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,42799-0806-01,NDC,outpatient,1,UN,14.59,10.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,00006-0032-20,NDC,outpatient,1,UN,19.14,13.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,00904-7052-61,NDC,outpatient,1,UN,2.19,1.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-20,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-01,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-20,NDC,outpatient,1,UN,6.84,4.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,00378-6410-01,NDC,outpatient,1,UN,5.48,3.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-01,NDC,outpatient,1,UN,6.84,4.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,00378-3125-01,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-01,NDC,outpatient,1,UN,2.89,2.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-20,NDC,outpatient,1,UN,2.89,2.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1101-45,NDC,outpatient,85,GR,10.6,7.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1349-57,NDC,outpatient,85,GR,9.08,6.356,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,57896-0116-03,NDC,outpatient,85,GR,10.97,7.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-11,NDC,outpatient,1,UN,45.64,31.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-10,NDC,outpatient,1,UN,107.52,75.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-10,NDC,outpatient,1,UN,49.76,34.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-10,NDC,outpatient,1,UN,68.55,47.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-01,NDC,outpatient,1,UN,107.52,75.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-01,NDC,outpatient,1,UN,49.76,34.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-00,NDC,outpatient,1,UN,68.55,47.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-02,NDC,outpatient,1,UN,45.64,31.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,00904-6474-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-51,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-80,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00904-0430-06,NDC,outpatient,1,UN,5.29,3.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00143-2112-50,NDC,outpatient,1,UN,1.07,0.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-21,NDC,outpatient,1,UN,4.84,3.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-11,NDC,outpatient,1,UN,4.84,3.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-11,NDC,outpatient,1,UN,4.16,2.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-01,NDC,outpatient,1,UN,4.16,2.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,31722-0632-31,NDC,outpatient,1,UN,4.28,2.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,64380-0799-01,NDC,outpatient,1,UN,8.24,5.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,27241-0049-10,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-11,NDC,outpatient,1,UN,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-21,NDC,outpatient,1,UN,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EXEMESTANE 25 MG ORAL TABS,RX-26551,CDM,S5000,HCPCS,259,RC,59762-2858-01,NDC,outpatient,1,UN,6.65,4.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,65862-0246-08,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,00904-7124-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MOXIFLOXACIN HCL 400 MG ORAL TABS,RX-26854,CDM,S5000,HCPCS,259,RC,65862-0603-30,NDC,outpatient,1,UN,13.67,9.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,16729-0490-12,NDC,outpatient,1,UN,6.58,4.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,69452-0131-17,NDC,outpatient,1,UN,2.23,1.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,72205-0039-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,69452-0132-17,NDC,outpatient,1,UN,2.23,1.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,00904-6682-08,NDC,outpatient,1,UN,13.18,9.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,42291-0412-60,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,00904-6683-08,NDC,outpatient,1,UN,13.31,9.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,42291-0413-60,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TERBINAFINE HCL 1 % EX CREA,RX-27023,CDM,S5000,HCPCS,259,RC,51672-2080-01,NDC,outpatient,15,GR,24.57,17.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,S5000,HCPCS,259,RC,11980-0174-05,NDC,outpatient,5,ML,659.54,461.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-11,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-01,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHARCOAL ACTIVATED ORAL LIQD,RX-27099,CDM,S5000,HCPCS,259,RC,66689-0202-04,NDC,outpatient,120,ML,82.77,57.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISEDRONATE SODIUM 5 MG ORAL TABS,RX-27112,CDM,S5000,HCPCS,259,RC,33342-0107-07,NDC,outpatient,1,UN,11.13,7.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,47335-0539-81,NDC,outpatient,1,UN,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,59651-0018-90,NDC,outpatient,1,UN,1.7,1.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-0038-01,NDC,outpatient,454,GR,8.09,5.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,49580-0394-04,NDC,outpatient,1814,GR,16.15,11.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-1210-01,NDC,outpatient,454,GR,8.09,5.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-10,NDC,outpatient,10,ML,39.03,27.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-02,NDC,outpatient,2,ML,34.38,24.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE ER 100 MG ORAL CP24,RX-27418,CDM,S5000,HCPCS,259,RC,52244-0100-10,NDC,outpatient,1,UN,14.48,10.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,S5000,HCPCS,250,RC,63323-0113-10,NDC,outpatient,1,UN,686.14,480.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,S5000,HCPCS,259,RC,55566-2800-01,NDC,outpatient,1,UN,2100.63,1470.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-93,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-16,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-16,NDC,outpatient,1,UN,2.2,1.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-93,NDC,outpatient,1,UN,2.2,1.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-01,NDC,outpatient,1,UN,217.89,152.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-30,NDC,outpatient,1,UN,217.89,152.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,43598-0894-30,NDC,outpatient,1,UN,9.32,6.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-93,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-16,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-16,NDC,outpatient,1,UN,3.17,2.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-93,NDC,outpatient,1,UN,3.17,2.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,13668-0132-01,NDC,outpatient,1,UN,1.96,1.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,00603-3581-21,NDC,outpatient,1,UN,1.73,1.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,68462-0233-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,00536-1161-37,NDC,outpatient,1,UN,1.77,1.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,63824-0056-34,NDC,outpatient,1,UN,1.93,1.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-11,NDC,outpatient,1,UN,3.24,2.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-01,NDC,outpatient,1,UN,3.24,2.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68382-0106-01,NDC,outpatient,1,UN,1.55,1.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-11,NDC,outpatient,1,UN,7.06,4.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-13,NDC,outpatient,1,UN,7.06,4.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE ER 300 MG ORAL CP12,RX-27633,CDM,S5000,HCPCS,259,RC,66993-0409-32,NDC,outpatient,1,UN,5.66,3.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE ER 100 MG ORAL TB12,RX-27634,CDM,S5000,HCPCS,259,RC,51672-4123-01,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE ER 400 MG ORAL TB12,RX-27636,CDM,S5000,HCPCS,259,RC,51672-4125-01,NDC,outpatient,1,UN,2.24,1.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,49884-0007-02,NDC,outpatient,1,UN,22.19,15.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,68462-0405-60,NDC,outpatient,1,UN,2.36,1.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-01,NDC,outpatient,1,UN,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-11,NDC,outpatient,1,UN,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,62175-0262-37,NDC,outpatient,1,UN,9.51,6.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-11,NDC,outpatient,1,UN,11.24,7.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-21,NDC,outpatient,1,UN,11.24,7.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,S5000,HCPCS,259,RC,17238-0900-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,S5000,HCPCS,259,RC,41167-0057-24,NDC,outpatient,141,GR,30.75,21.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,RX-27770,CDM,S5000,HCPCS,259,RC,24208-0342-05,NDC,outpatient,5,ML,655.13,458.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-11,NDC,outpatient,1,UN,2.24,1.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-15,NDC,outpatient,1,UN,2.24,1.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-41,NDC,outpatient,50,ML,22.94,16.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-48,NDC,outpatient,100,ML,22.69,15.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,,,outpatient,500,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-02,NDC,outpatient,250,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-02,NDC,outpatient,250,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-04,NDC,outpatient,500,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00409-7101-67,NDC,outpatient,100,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00487-4301-10,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-38,NDC,outpatient,100,ML,22.17,15.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-11,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-01,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-01,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-11,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,00904-7077-61,NDC,outpatient,1,UN,1.54,1.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,S5000,HCPCS,259,RC,43598-0446-74,NDC,outpatient,1,UN,4.78,3.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,S5000,HCPCS,259,RC,43598-0447-74,NDC,outpatient,1,UN,5.28,3.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-88,NDC,outpatient,1,UN,7.5,5.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-28,NDC,outpatient,1,UN,5.25,3.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-74,NDC,outpatient,1,UN,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-33,NDC,outpatient,1,UN,7.5,5.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,62135-0712-42,NDC,outpatient,5,ML,20.16,14.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,99999-0002-05,NDC,outpatient,15,ML,60.48,42.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,00054-3500-49,NDC,outpatient,5,ML,2.23,1.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,72888-0125-26,NDC,outpatient,5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-47,NDC,outpatient,1,UN,17.49,12.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-11,NDC,outpatient,1,UN,17.49,12.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-98,NDC,outpatient,1,UN,37.78,26.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-11,NDC,outpatient,1,UN,25.49,17.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-47,NDC,outpatient,1,UN,25.49,17.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-16,NDC,outpatient,1,UN,37.78,26.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-11,NDC,outpatient,1,UN,37.66,26.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-47,NDC,outpatient,1,UN,37.66,26.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-16,NDC,outpatient,1,UN,93.74,65.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-98,NDC,outpatient,1,UN,93.74,65.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-30,NDC,outpatient,1,UN,4.71,3.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-10,NDC,outpatient,1,UN,3.99,2.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML ORAL SUSP,RX-27999,CDM,S5000,HCPCS,259,RC,46287-0006-60,NDC,outpatient,60,ML,91.85,64.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,16714-0601-02,NDC,outpatient,2.5,ML,10.37,7.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,99999-0003-51,NDC,outpatient,2.5,ML,10.37,7.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FE FUMARATE-B12-VIT C-FA-IFC ORAL CAPS,RX-28030,CDM,S5000,HCPCS,259,RC,51991-0635-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-01,NDC,outpatient,78,GR,22.91,16.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-02,NDC,outpatient,56,GR,17.7,12.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN BUF(CACARB-MGCARB-MGO) 325 MG ORAL TABS,RX-28122,CDM,S5000,HCPCS,259,RC,00904-2015-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-19,NDC,outpatient,1,UN,2.89,2.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-65,NDC,outpatient,1,UN,2.89,2.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,33342-0083-07,NDC,outpatient,1,UN,3.81,2.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-81,NDC,outpatient,1,UN,3.06,2.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-79,NDC,outpatient,1,UN,3.06,2.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,60505-3275-00,NDC,outpatient,1,UN,1.9,1.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-52,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-55,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-33,NDC,outpatient,1,UN,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-84,NDC,outpatient,1,UN,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,00904-6553-04,NDC,outpatient,1,UN,7.73,5.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,59762-1308-04,NDC,outpatient,150,ML,1694.12,1185.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,99999-0002-85,NDC,outpatient,30,ML,340.43,238.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,S5000,HCPCS,259,RC,63323-0877-15,NDC,outpatient,1,UN,686.24,480.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAPS,RX-28278,CDM,S5000,HCPCS,259,RC,00904-7107-61,NDC,outpatient,1,UN,10.27,7.189,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE TARTRATE 3 MG ORAL CAPS,RX-28279,CDM,S5000,HCPCS,259,RC,55111-0353-60,NDC,outpatient,1,UN,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN GLARGINE 100 UNIT/ML SC SOLN,RX-28282,CDM,S5000,HCPCS,259,RC,00088-2220-33,NDC,outpatient,10,ML,252.19,176.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-25,NDC,outpatient,1,UN,13.08,9.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-95,NDC,outpatient,1,UN,13.08,9.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-62,NDC,outpatient,1,UN,2,1.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-23,NDC,outpatient,1,UN,2,1.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-99,NDC,outpatient,1,UN,65.95,46.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-16,NDC,outpatient,1,UN,65.95,46.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-99,NDC,outpatient,1,UN,65.26,45.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-16,NDC,outpatient,1,UN,65.26,45.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-11,NDC,outpatient,1,UN,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-01,NDC,outpatient,1,UN,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,13811-0706-10,NDC,outpatient,1,UN,3.22,2.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,50458-0585-01,NDC,outpatient,1,UN,53.04,37.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00186-1988-04,NDC,outpatient,2,ML,35.8,25.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00487-9601-01,NDC,outpatient,2,ML,17.76,12.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-05,NDC,outpatient,2,ML,5.21,3.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-87,NDC,outpatient,2,ML,8.61,6.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-53,NDC,outpatient,2,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-45,NDC,outpatient,2,ML,39.45,27.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-73,NDC,outpatient,2,ML,39.45,27.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,47335-0632-49,NDC,outpatient,1,ML,6.14,4.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-32,NDC,outpatient,2,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00487-9701-01,NDC,outpatient,2,ML,14.93,10.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-30,NDC,outpatient,2,ML,5.21,3.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-86,NDC,outpatient,2,ML,8.61,6.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-16,NDC,outpatient,453.6,GR,58.59,41.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-21,NDC,outpatient,28.35,GR,7.2,5.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,38779-3068-00,NDC,outpatient,30,GR,75.03,52.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2311-00,NDC,outpatient,52.5,GR,7.25,5.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2335-00,NDC,outpatient,390,GR,19.1,13.37,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,08080-4302-01,NDC,outpatient,30,ML,5.88,4.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,53329-0993-04,NDC,outpatient,113,GR,5.26,3.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,24208-0635-62,NDC,outpatient,10,ML,221.08,154.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,61314-0645-11,NDC,outpatient,10,ML,217.88,152.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLYCERIN LIQD,RX-28815,CDM,S5000,HCPCS,259,RC,00395-1031-96,NDC,outpatient,177,ML,23.63,16.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP,RX-28836,CDM,S5000,HCPCS,259,RC,00121-0431-30,NDC,outpatient,30,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-19,NDC,outpatient,1,UN,1.84,1.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-65,NDC,outpatient,1,UN,1.84,1.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-61,NDC,outpatient,1,UN,46.19,32.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-15,NDC,outpatient,1,UN,46.19,32.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,RX-28844,CDM,S5000,HCPCS,259,RC,00172-7313-20,NDC,outpatient,50,ML,396.5,277.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN 2 % EX SOLN,RX-2887,CDM,S5000,HCPCS,259,RC,45802-0038-46,NDC,outpatient,60,ML,71.56,50.092,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-11,NDC,outpatient,1,GR,31.37,21.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-50,NDC,outpatient,1,GR,31.37,21.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,48102-0057-11,NDC,outpatient,1,GR,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,24208-0910-19,NDC,outpatient,1,GR,31.03,21.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-11,NDC,outpatient,1,UN,4.25,2.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-59,NDC,outpatient,1,UN,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-01,NDC,outpatient,1,UN,4.25,2.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-23,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-62,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-61,NDC,outpatient,1,UN,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,13668-0586-30,NDC,outpatient,1,UN,21.71,15.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,24338-0122-03,NDC,outpatient,1,UN,24.57,17.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NA HYALUR & NA CHOND-NA HYALUR 0.4-0.35 ML IO KIT,RX-28916,CDM,S5000,HCPCS,250,RC,08065-1831-35,NDC,outpatient,0.75,ML,867.31,607.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOFLOXACIN 750 MG ORAL TABS,RX-28964,CDM,S5000,HCPCS,259,RC,00904-6353-61,NDC,outpatient,1,UN,2.17,1.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,24338-0134-02,NDC,outpatient,100,ML,1005.7,703.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,99999-0002-77,NDC,outpatient,5,ML,50.87,35.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,75834-0295-01,NDC,outpatient,100,ML,494.4,346.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,51224-0007-50,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,70010-0491-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALENDRONATE SODIUM 70 MG ORAL TABS,RX-29048,CDM,S5000,HCPCS,259,RC,16714-0633-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALENDRONATE SODIUM 35 MG ORAL TABS,RX-29072,CDM,S5000,HCPCS,259,RC,16714-0632-01,NDC,outpatient,1,UN,5.43,3.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-90,NDC,outpatient,473,ML,168.39,117.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,99999-0003-42,NDC,outpatient,6,ML,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-06,NDC,outpatient,6,ML,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-07,NDC,outpatient,470,ML,154.78,108.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-06,NDC,outpatient,6,ML,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-06,NDC,outpatient,6,ML,15.62,10.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-16,NDC,outpatient,470,ML,144.32,101.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-40,NDC,outpatient,6,ML,15.62,10.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-30,NDC,outpatient,1,UN,1.44,1.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-01,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-11,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,68682-0993-98,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,00904-7218-61,NDC,outpatient,1,UN,1.28,0.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,62037-0598-90,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-11,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,00904-7219-61,NDC,outpatient,1,UN,1.59,1.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-01,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-11,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,24979-0029-07,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-01,NDC,outpatient,1,UN,6.23,4.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-11,NDC,outpatient,1,UN,6.23,4.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCOSANOL 10 % EX CREA,RX-29287,CDM,S5000,HCPCS,259,RC,00135-0300-01,NDC,outpatient,2,GR,72.76,50.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,00054-0079-28,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-11,NDC,outpatient,1,UN,5.8,4.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-13,NDC,outpatient,1,UN,5.8,4.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,60505-2575-07,NDC,outpatient,1,UN,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,65649-0101-02,NDC,outpatient,1,UN,26.86,18.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,72789-0149-69,NDC,outpatient,1,UN,1.89,1.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,00168-0258-15,NDC,outpatient,15,GR,71.29,49.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,16714-0496-01,NDC,outpatient,15,GR,55.61,38.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-11,NDC,outpatient,1,UN,7.98,5.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-21,NDC,outpatient,1,UN,7.98,5.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIRTAZAPINE 15 MG ORAL TBDP,RX-29531,CDM,S5000,HCPCS,259,RC,65862-0021-06,NDC,outpatient,1,UN,1.96,1.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIPRASIDONE HCL 20 MG ORAL CAPS,RX-29778,CDM,S5000,HCPCS,259,RC,00904-6269-08,NDC,outpatient,1,UN,11.99,8.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-11,NDC,outpatient,1,UN,7.81,5.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-11,NDC,outpatient,1,UN,7.96,5.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-09,NDC,outpatient,1,UN,7.81,5.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-12,NDC,outpatient,1,UN,7.96,5.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,00781-2168-60,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-09,NDC,outpatient,1,UN,7.81,5.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-11,NDC,outpatient,1,UN,7.81,5.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-21,NDC,outpatient,1,UN,14.03,9.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-11,NDC,outpatient,1,UN,14.03,9.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,70436-0004-06,NDC,outpatient,1,UN,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-61,NDC,outpatient,1,UN,2.19,1.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-06,NDC,outpatient,1,UN,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,50742-0615-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,45963-0709-11,NDC,outpatient,1,UN,1.28,0.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-01,NDC,outpatient,1,UN,2.11,1.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-20,NDC,outpatient,1,UN,2.11,1.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EYE STREAM OP SOLN,RX-2999,CDM,S5000,HCPCS,259,RC,00065-0530-01,NDC,outpatient,30,ML,81.97,57.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-01,NDC,outpatient,1,UN,1.9,1.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,68382-0565-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,00904-6323-61,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,50742-0616-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-20,NDC,outpatient,1,UN,1.9,1.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,00904-6324-61,NDC,outpatient,1,UN,2.66,1.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-15,NDC,outpatient,1,UN,2.35,1.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-11,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-03,NDC,outpatient,1,UN,5.81,4.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-01,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-01,NDC,outpatient,1,UN,5.81,4.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-11,NDC,outpatient,1,UN,2.35,1.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-25,NDC,outpatient,1,UN,121.31,84.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-95,NDC,outpatient,1,UN,121.31,84.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,63739-0357-33,NDC,outpatient,1,UN,93.6,65.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CITALOPRAM HYDROBROMIDE 10 MG ORAL TABS,RX-30264,CDM,S5000,HCPCS,259,RC,00904-6084-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-59,NDC,outpatient,5,ML,23.66,16.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,99999-0002-25,NDC,outpatient,5,ML,33.09,23.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,00078-0357-52,NDC,outpatient,5,ML,39.3,27.51,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-62,NDC,outpatient,5,ML,23.66,16.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MELATONIN 5 MG SL SUBL,RX-30511,CDM,S5000,HCPCS,259,RC,54629-0615-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7591-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,20555-0021-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7590-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,16714-0576-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-20,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-01,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,55111-0729-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,00904-7041-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-20,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,00904-6572-61,NDC,outpatient,1,UN,1.71,1.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-01,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,00143-9853-75,NDC,outpatient,75,ML,63.42,44.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,99999-0002-82,NDC,outpatient,5,ML,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,31722-0153-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-01,NDC,outpatient,1,UN,4.62,3.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-11,NDC,outpatient,1,UN,4.62,3.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,33342-0064-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,65162-0778-10,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,00574-9855-10,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,76204-0010-55,NDC,outpatient,3,ML,1.98,1.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,00487-0301-01,NDC,outpatient,3,ML,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-01,NDC,outpatient,3,ML,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-25,NDC,outpatient,3,ML,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,00228-3059-11,NDC,outpatient,1,UN,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,64850-0511-01,NDC,outpatient,1,UN,2,1.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,70010-0030-01,NDC,outpatient,1,UN,3.45,2.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,54295-0312-18,NDC,outpatient,226.8,GR,419.86,293.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,81542-0201-08,NDC,outpatient,226.8,GR,454.17,317.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TABS,RX-31684,CDM,S5000,HCPCS,259,RC,61958-0401-01,NDC,outpatient,1,UN,180.36,126.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,00093-0262-15,NDC,outpatient,15,GR,162.14,113.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,51672-1386-01,NDC,outpatient,15,GR,35.32,24.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,S5000,HCPCS,259,RC,51672-1264-01,NDC,outpatient,15,GR,55.01,38.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,S5000,HCPCS,259,RC,51672-1273-02,NDC,outpatient,20,ML,137.87,96.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,S5000,HCPCS,259,RC,60758-0880-05,NDC,outpatient,5,ML,308.83,216.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUPHENAZINE HCL 1 MG ORAL TABS,RX-3218,CDM,S5000,HCPCS,259,RC,00527-1788-01,NDC,outpatient,1,UN,6.6,4.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,70954-0274-10,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,00527-1789-01,NDC,outpatient,1,UN,10.2,7.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,00527-1790-01,NDC,outpatient,1,UN,13.8,9.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,69238-1680-01,NDC,outpatient,1,UN,6.45,4.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,39822-1100-01,NDC,outpatient,0.2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,63323-0184-10,NDC,outpatient,0.2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,00904-7224-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,00781-1061-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,65862-0676-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALPRAZOLAM 0.5 MG ORAL TABS,RX-325,CDM,S5000,HCPCS,259,RC,00781-1077-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAROXETINE HCL ER 12.5 MG ORAL TB24,RX-32631,CDM,S5000,HCPCS,259,RC,62175-0470-32,NDC,outpatient,1,UN,4.97,3.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPHENIDATE HCL ER (OSM) 27 MG ORAL TBCR,RX-32654,CDM,S5000,HCPCS,259,RC,13811-0707-10,NDC,outpatient,1,UN,3.33,2.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,68462-0437-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,00713-0861-30,NDC,outpatient,1,UN,39.98,27.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,33342-0179-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISEDRONATE SODIUM 35 MG ORAL TABS,RX-32895,CDM,S5000,HCPCS,259,RC,33342-0109-50,NDC,outpatient,1,UN,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-59,NDC,outpatient,4,ML,7.04,4.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-62,NDC,outpatient,4,ML,7.04,4.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-59,NDC,outpatient,5,ML,7.04,4.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-62,NDC,outpatient,5,ML,7.04,4.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00904-7177-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00054-8297-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,00054-8301-25,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMPHETAMINE-DEXTROAMPHET ER 5 MG ORAL CP24,RX-33005,CDM,S5000,HCPCS,259,RC,54092-0381-01,NDC,outpatient,1,UN,29.29,20.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VORICONAZOLE 200 MG ORAL TABS,RX-33009,CDM,S5000,HCPCS,259,RC,00904-7024-04,NDC,outpatient,1,UN,43.81,30.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TABS,RX-33227,CDM,S5000,HCPCS,259,RC,00781-1831-01,NDC,outpatient,1,UN,1.59,1.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,00143-9249-20,NDC,outpatient,1,UN,5.26,3.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-01,NDC,outpatient,1,UN,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-20,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,42571-0162-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-01,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,00904-6426-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-11,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,31722-0151-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-11,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-21,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-01,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-11,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METAXALONE 800 MG ORAL TABS,RX-33963,CDM,S5000,HCPCS,259,RC,00527-1435-01,NDC,outpatient,1,UN,2.54,1.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DUTASTERIDE 0.5 MG ORAL CAPS,RX-34089,CDM,S5000,HCPCS,259,RC,42806-0549-09,NDC,outpatient,1,UN,1.7,1.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-11,NDC,outpatient,1,UN,18.75,13.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,51660-0200-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-21,NDC,outpatient,1,UN,18.75,13.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,00904-7103-04,NDC,outpatient,1,UN,18.36,12.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,S5000,HCPCS,259,RC,45802-0056-35,NDC,outpatient,15,GR,170.02,119.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,S5000,HCPCS,259,RC,45802-0046-35,NDC,outpatient,15,GR,132.44,92.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,24208-0580-60,NDC,outpatient,5,ML,23.41,16.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,61314-0633-05,NDC,outpatient,5,ML,21.99,15.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-01,NDC,outpatient,1,UN,22.5,15.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-11,NDC,outpatient,1,UN,22.5,15.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,63739-0078-33,NDC,outpatient,1,UN,22.38,15.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,27241-0054-03,NDC,outpatient,1,UN,2.88,2.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-11,NDC,outpatient,1,UN,27.24,19.068,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-21,NDC,outpatient,1,UN,27.24,19.068,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-01,NDC,outpatient,1,UN,2.75,1.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-11,NDC,outpatient,1,UN,2.75,1.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,31722-0714-30,NDC,outpatient,1,UN,8.16,5.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,35573-0415-30,NDC,outpatient,1,UN,14,9.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,68462-0265-30,NDC,outpatient,1,UN,4.5,3.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,55111-0519-30,NDC,outpatient,1,UN,7.25,5.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,16714-0757-01,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,64980-0375-03,NDC,outpatient,1,UN,7.25,5.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,68462-0268-30,NDC,outpatient,1,UN,2.91,2.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,00093-3545-56,NDC,outpatient,1,UN,17.9,12.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-95,NDC,outpatient,1,UN,14.68,10.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-25,NDC,outpatient,1,UN,14.68,10.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-23,NDC,outpatient,1,UN,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-62,NDC,outpatient,1,UN,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-21,NDC,outpatient,1,UN,6.96,4.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-11,NDC,outpatient,1,UN,6.96,4.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,42858-0502-03,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-11,NDC,outpatient,1,UN,11.98,8.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-21,NDC,outpatient,1,UN,11.98,8.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,00054-0188-13,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,65162-0416-03,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-11,NDC,outpatient,1,UN,14.96,10.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-15,NDC,outpatient,1,UN,14.96,10.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,42858-0602-03,NDC,outpatient,1,UN,27,18.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,61314-0646-10,NDC,outpatient,10,ML,188.28,131.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,24208-0631-10,NDC,outpatient,10,ML,205.06,143.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-11,NDC,outpatient,1,UN,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,00904-6779-61,NDC,outpatient,1,UN,3.97,2.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-01,NDC,outpatient,1,UN,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,16714-0990-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-11,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-01,NDC,outpatient,1,UN,5.36,3.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-11,NDC,outpatient,1,UN,5.36,3.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,00904-6780-61,NDC,outpatient,1,UN,3.57,2.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-15,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,S5000,HCPCS,259,RC,00023-9163-30,NDC,outpatient,1,UN,44.22,30.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,99999-0002-48,NDC,outpatient,30,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,00536-0091-85,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GRISEOFULVIN ULTRAMICROSIZE 250 MG ORAL TABS,RX-3536,CDM,S5000,HCPCS,259,RC,00115-1725-01,NDC,outpatient,1,UN,20.98,14.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-08,NDC,outpatient,1,UN,349.43,244.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-08,NDC,outpatient,1,UN,10.21,7.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-01,NDC,outpatient,1,UN,349.43,244.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-01,NDC,outpatient,1,UN,10.21,7.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-52,NDC,outpatient,1,UN,2.41,1.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-55,NDC,outpatient,1,UN,2.41,1.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-55,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-52,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,72266-0158-01,NDC,outpatient,3,ML,45.03,31.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,00832-1410-03,NDC,outpatient,3,ML,113.88,79.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,67877-0414-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,70010-0492-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,62756-0143-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00832-1530-11,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00378-0214-01,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-20,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-01,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,54838-0501-15,NDC,outpatient,0.5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,99999-0003-09,NDC,outpatient,0.5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-89,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-01,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,63739-0972-10,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-01,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00832-5325-11,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-89,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATAZANAVIR SULFATE 150 MG ORAL CAPS,RX-36149,CDM,S5000,HCPCS,259,RC,42385-0920-60,NDC,outpatient,1,UN,11.33,7.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATAZANAVIR SULFATE 200 MG ORAL CAPS,RX-36150,CDM,S5000,HCPCS,259,RC,65862-0712-60,NDC,outpatient,1,UN,13.22,9.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREMASOL 10 % IV SOLN,RX-36160,CDM,S5000,HCPCS,250,RC,00338-1130-03,NDC,outpatient,500,ML,98.33,68.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EMTRICITABINE 200 MG ORAL CAPS,RX-36252,CDM,S5000,HCPCS,259,RC,61958-0601-01,NDC,outpatient,1,UN,77.2,54.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-11,NDC,outpatient,1,UN,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-15,NDC,outpatient,1,UN,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-01,NDC,outpatient,1,UN,15.64,10.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-11,NDC,outpatient,1,UN,15.64,10.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,16714-0628-01,NDC,outpatient,7.5,ML,422.83,295.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,43598-0326-75,NDC,outpatient,7.5,ML,438.69,307.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,62756-0427-90,NDC,outpatient,7.5,ML,336.96,235.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-40,NDC,outpatient,5,ML,9.93,6.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-67,NDC,outpatient,5,ML,12.02,8.414,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-05,NDC,outpatient,5,ML,9.93,6.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-40,NDC,outpatient,5,ML,12.02,8.414,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROSUVASTATIN CALCIUM 5 MG ORAL TABS,RX-36612,CDM,S5000,HCPCS,259,RC,00904-6778-61,NDC,outpatient,1,UN,2.9,2.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETOROLAC TROMETHAMINE 0.4 % OP SOLN,RX-36631,CDM,S5000,HCPCS,259,RC,60758-0773-05,NDC,outpatient,5,ML,248.94,174.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-04,NDC,outpatient,1,UN,5.27,3.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-61,NDC,outpatient,1,UN,6.35,4.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,16729-0443-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-10,NDC,outpatient,10,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-01,NDC,outpatient,10,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-10,NDC,outpatient,10,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-00,NDC,outpatient,10,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,99999-0001-96,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,42858-0701-01,NDC,outpatient,1,UN,3.89,2.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,29033-0001-01,NDC,outpatient,1,UN,5.44,3.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,49348-0991-36,NDC,outpatient,177,ML,7.88,5.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,78112-0011-03,NDC,outpatient,177,ML,17.33,12.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,00904-6305-21,NDC,outpatient,177,ML,7.09,4.963,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,57237-0114-90,NDC,outpatient,1,UN,2,1.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,29300-0155-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-11,NDC,outpatient,1,UN,18.55,12.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-21,NDC,outpatient,1,UN,18.55,12.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,51991-0877-33,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,59762-1710-02,NDC,outpatient,1,UN,5.59,3.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZONISAMIDE 25 MG ORAL CAPS,RX-36987,CDM,S5000,HCPCS,259,RC,68462-0128-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,31722-0520-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,63739-0327-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,23155-0833-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-01,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-20,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,57896-0621-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,00536-3445-08,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-44,NDC,outpatient,1,UN,1.42,0.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00904-6505-61,NDC,outpatient,1,UN,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-11,NDC,outpatient,1,UN,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-45,NDC,outpatient,1,UN,1.42,0.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-57,NDC,outpatient,1,UN,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00832-1112-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,00536-1277-80,NDC,outpatient,28,GR,5.24,3.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,49348-0521-72,NDC,outpatient,28.4,GR,6.32,4.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00394-0859-32,NDC,outpatient,114,ML,22.83,15.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00096-0732-04,NDC,outpatient,120,ML,56.61,39.627,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,S5000,HCPCS,259,RC,00168-0020-31,NDC,outpatient,28.35,GR,18.05,12.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-01,NDC,outpatient,1,UN,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,59762-0074-01,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-11,NDC,outpatient,1,UN,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,00574-7090-12,NDC,outpatient,1,UN,5.54,3.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,10135-0751-12,NDC,outpatient,1,UN,7.8,5.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-60,NDC,outpatient,1,UN,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-95,NDC,outpatient,1,UN,3.48,2.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-98,NDC,outpatient,1,UN,3.48,2.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-65,NDC,outpatient,1,UN,2.84,1.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-89,NDC,outpatient,1,UN,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-63,NDC,outpatient,1,UN,2.84,1.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-13,NDC,outpatient,1,UN,7.06,4.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-11,NDC,outpatient,1,UN,7.06,4.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BSS IO SOLN,RX-37579,CDM,S5000,HCPCS,259,RC,00065-0795-15,NDC,outpatient,15,ML,24.7,17.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,00406-3243-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-01,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-01,NDC,outpatient,1,UN,1.27,0.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-11,NDC,outpatient,1,UN,1.27,0.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-11,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,00406-3244-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,42858-0234-01,NDC,outpatient,1,UN,17.03,11.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-01,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,00378-0018-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,23155-0603-51,NDC,outpatient,100,ML,170.44,119.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,59762-0016-01,NDC,outpatient,100,ML,170.44,119.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,99999-0002-90,NDC,outpatient,10,ML,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-11,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-21,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-01,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-11,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-01,NDC,outpatient,1,UN,2.76,1.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,63824-0008-50,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-11,NDC,outpatient,1,UN,2.76,1.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,00904-6718-39,NDC,outpatient,1,UN,2.32,1.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,54838-0502-80,NDC,outpatient,5,ML,2.88,2.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,99999-0002-50,NDC,outpatient,5,ML,1.16,0.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,62135-0750-47,NDC,outpatient,5,ML,21.74,15.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYZINE HCL 10 MG ORAL TABS,RX-3772,CDM,S5000,HCPCS,259,RC,63739-0483-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,63739-0486-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,00904-6617-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TALC 5 G PL SUSR,RX-37812,CDM,S5000,HCPCS,259,RC,63256-0200-05,NDC,outpatient,1,UN,458.35,320.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,55513-0073-30,NDC,outpatient,1,UN,75.45,52.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,00904-7067-04,NDC,outpatient,1,UN,76.53,53.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-21,NDC,outpatient,1,UN,64.87,45.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,70436-0007-04,NDC,outpatient,1,UN,1.94,1.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-11,NDC,outpatient,1,UN,64.87,45.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ORPHENADRINE CITRATE ER 100 MG ORAL TB12,RX-38213,CDM,S5000,HCPCS,259,RC,43386-0480-24,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,62559-0530-01,NDC,outpatient,1,UN,2.1,1.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,00228-2778-11,NDC,outpatient,1,UN,6.75,4.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,42291-0522-01,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00228-2779-11,NDC,outpatient,1,UN,8.57,5.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00527-4117-37,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,42291-0524-01,NDC,outpatient,1,UN,2.42,1.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,00228-2780-11,NDC,outpatient,1,UN,10.29,7.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-00,NDC,outpatient,30,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-65,NDC,outpatient,15,ML,1.01,0.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-30,NDC,outpatient,30,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-30,NDC,outpatient,30,ML,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,99999-0001-83,NDC,outpatient,30,ML,2.16,1.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-64,NDC,outpatient,1,UN,12.96,9.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-06,NDC,outpatient,1,UN,12.96,9.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 200 MG ORAL TABS,RX-3841,CDM,S5000,HCPCS,259,RC,00904-7914-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 600 MG ORAL TABS,RX-3844,CDM,S5000,HCPCS,259,RC,00904-5854-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-01,NDC,outpatient,4,ML,53.96,37.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-09,NDC,outpatient,1,ML,15.58,10.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IBUPROFEN 800 MG ORAL TABS,RX-3845,CDM,S5000,HCPCS,259,RC,00904-5855-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUOXETINE HCL 20 MG/5ML ORAL SOLN,RX-38488,CDM,S5000,HCPCS,259,RC,00121-4721-05,NDC,outpatient,5,ML,14.38,10.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IMIPRAMINE HCL 10 MG ORAL TABS,RX-3860,CDM,S5000,HCPCS,259,RC,69584-0425-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IMIPRAMINE HCL 25 MG ORAL TABS,RX-3861,CDM,S5000,HCPCS,259,RC,69584-0426-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,S5000,HCPCS,259,RC,24208-0780-55,NDC,outpatient,3.5,GR,57.59,40.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,62559-0511-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,00228-2571-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SELENIUM SULFIDE 1 % EX SHAM,RX-38961,CDM,S5000,HCPCS,259,RC,00536-1995-53,NDC,outpatient,207,ML,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PEG 3350-KCL-NABCB-NACL-NASULF 240 G ORAL SOLR,RX-38965,CDM,S5000,HCPCS,259,RC,43386-0060-19,NDC,outpatient,4000,ML,53.4,37.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-15,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-11,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,S5000,HCPCS,259,RC,69344-0102-33,NDC,outpatient,1,UN,1095.8,767.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAXIMIN 200 MG ORAL TABS,RX-39063,CDM,S5000,HCPCS,259,RC,65649-0301-03,NDC,outpatient,1,UN,43.55,30.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMILORIDE HCL 5 MG ORAL TABS,RX-391,CDM,S5000,HCPCS,259,RC,00574-0292-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68382-0370-01,NDC,outpatient,15,GR,31.18,21.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,16714-0769-01,NDC,outpatient,15,GR,25.04,17.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,69315-0306-15,NDC,outpatient,15,GR,24.5,17.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,00832-0465-15,NDC,outpatient,15,GR,37.52,26.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68308-0152-15,NDC,outpatient,15,GR,27.84,19.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EMTRICITABINE-TENOFOVIR DF 200-300 MG ORAL TABS,RX-39255,CDM,S5000,HCPCS,259,RC,61958-0701-01,NDC,outpatient,1,UN,265.08,185.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-11,NDC,outpatient,1,UN,3.39,2.373,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,00904-7043-04,NDC,outpatient,1,UN,3.3,2.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-21,NDC,outpatient,1,UN,3.39,2.373,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,57237-0018-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-01,NDC,outpatient,1,UN,3.41,2.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-11,NDC,outpatient,1,UN,3.41,2.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,00904-7044-61,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-93,NDC,outpatient,1,UN,20.14,14.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-31,NDC,outpatient,1,UN,20.14,14.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,99999-0002-80,NDC,outpatient,6,ML,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,65862-0219-60,NDC,outpatient,60,ML,88.92,62.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,68180-0723-04,NDC,outpatient,60,ML,87.31,61.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE ER 500 MG ORAL CPCR,RX-39575,CDM,S5000,HCPCS,259,RC,54092-0191-12,NDC,outpatient,1,UN,24.97,17.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,48433-0230-15,NDC,outpatient,14,ML,132.64,92.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,51552-0019-44,NDC,outpatient,14,ML,5.44,3.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-25,NDC,outpatient,1,UN,6.9,4.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-95,NDC,outpatient,1,UN,6.9,4.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-01,NDC,outpatient,5,ML,12.98,9.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-10,NDC,outpatient,5,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-01,NDC,outpatient,5,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-10,NDC,outpatient,5,ML,12.98,9.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,63323-0424-05,NDC,outpatient,5,ML,15.68,10.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,00527-1948-68,NDC,outpatient,10,ML,85.98,60.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,99999-0002-53,NDC,outpatient,10,ML,37.07,25.949,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-45,NDC,outpatient,1,UN,49.37,34.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-90,NDC,outpatient,1,UN,49.37,34.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-42,NDC,outpatient,1,UN,24.73,17.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-52,NDC,outpatient,1,UN,24.73,17.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-20,NDC,outpatient,1,UN,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-01,NDC,outpatient,1,UN,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,51079-0608-20,NDC,outpatient,1,UN,10.74,7.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,60687-0629-21,NDC,outpatient,1,UN,4.19,2.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-01,NDC,outpatient,10,ML,19.54,13.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-04,NDC,outpatient,5,ML,14,9.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-61,NDC,outpatient,180,ML,12.46,8.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-82,NDC,outpatient,10,ML,19.54,13.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIFAMPIN 10 MG/ML ORAL SUSPENSION,RX-400484,CDM,S5000,HCPCS,259,RC,99999-0001-44,NDC,outpatient,120,ML,34,23.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,,,outpatient,12.5,ME,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,SH040-0403-01,NDC,outpatient,12.5,ME,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,99999-0002-12,NDC,outpatient,12.5,ME,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFAZOLIN EYE DROPS 50 MG/ML 20 ML BOTTLE,RX-400598,CDM,S5000,HCPCS,259,RC,SH408-0378-01,NDC,outpatient,20,ML,18.41,12.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,SH040-0620-01,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,,,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISONIAZID 100 MG ORAL TABS,RX-4026,CDM,S5000,HCPCS,259,RC,00555-0066-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-25,NDC,outpatient,4,ML,8,5.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-16,NDC,outpatient,20,ML,18.34,12.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-73,NDC,outpatient,20,ML,18.34,12.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-01,NDC,outpatient,4,ML,8,5.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-07,NDC,outpatient,5,ML,1453.64,1017.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-05,NDC,outpatient,5,ML,1453.64,1017.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,00548-9502-00,NDC,outpatient,5,ML,246.51,172.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,59762-0118-03,NDC,outpatient,1,UN,22.5,15.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,69918-0560-30,NDC,outpatient,1,UN,7.56,5.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SOLIFENACIN SUCCINATE 5 MG ORAL TABS,RX-40392,CDM,S5000,HCPCS,259,RC,51248-0150-01,NDC,outpatient,1,UN,52.84,36.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,00743-1203-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,74312-0035-95,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-11,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ISOSORBIDE DINITRATE 20 MG ORAL TABS,RX-4065,CDM,S5000,HCPCS,259,RC,00904-6620-61,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-10,NDC,outpatient,500,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-20,NDC,outpatient,250,ML,30.14,21.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROMORPHONE 100 MG/100 ML INFUSION,RX-4080055,CDM,S5000,HCPCS,250,RC,99999-0000-26,NDC,outpatient,100,ML,168.65,118.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM ADDVANTAGE INFUSION IN NS,RX-4080056,CDM,S5000,HCPCS,250,RC,99999-0000-00,NDC,outpatient,100,ML,54.5,38.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70092-1093-37,NDC,outpatient,250,ML,130.86,91.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0229-40,NDC,outpatient,250,ML,277.66,194.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,99999-0001-54,NDC,outpatient,250,ML,37.36,26.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0202-40,NDC,outpatient,250,ML,236.1,165.27,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,70004-0442-40,NDC,outpatient,250,ML,112.79,78.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,99999-9990-03,NDC,outpatient,250,ML,37.81,26.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE INFUSION 250 MG IN D5W 250 ML PREMIX,RX-4080096,CDM,S5000,HCPCS,250,RC,99999-0001-61,NDC,outpatient,250,ML,35.02,24.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-01,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-25,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-22,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-00,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,57896-0181-05,NDC,outpatient,15,ML,5.55,3.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,00065-0426-36,NDC,outpatient,15,ML,27.17,19.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAFCILLIN SODIUM 1 G IJ WRAPPER,RX-4080106,CDM,S5000,HCPCS,250,RC,63323-0327-10,NDC,outpatient,1,UN,15.49,10.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,44567-0222-10,NDC,outpatient,1,UN,90.46,63.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,63323-0328-20,NDC,outpatient,1,UN,24.64,17.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,55150-0123-15,NDC,outpatient,1,UN,30.45,21.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70004-0781-40,NDC,outpatient,250,ML,123.78,86.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70092-1650-05,NDC,outpatient,250,ML,102.2,71.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,71266-5020-02,NDC,outpatient,250,ML,112.97,79.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,42852-0838-25,NDC,outpatient,250,ML,158.85,111.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70092-9170-05,NDC,outpatient,250,ML,146.26,102.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70004-0812-40,NDC,outpatient,250,ML,93.12,65.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,70004-0811-40,NDC,outpatient,250,ML,109.23,76.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,71506-0010-58,NDC,outpatient,250,ML,88.76,62.132,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN DEXTROSE 1250 MG/250 ML IV SOLN,RX-4080122,CDM,S5000,HCPCS,250,RC,99999-0000-46,NDC,outpatient,275,ML,64.38,45.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN HCL IN DEXTROSE 1500 MG/250 ML IV SOLN,RX-4080123,CDM,S5000,HCPCS,250,RC,99999-0000-47,NDC,outpatient,280,ML,80.8,56.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARDIOPLEGIA SOLN HIGH POTASSIUM 4:1 INDUCTION,RX-4080154,CDM,S5000,HCPCS,250,RC,72196-0101-01,NDC,outpatient,500,ML,673.36,471.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARDIOPLEGIA SOLN LOW POTASSION 4:1 REPERFUSATE,RX-4080155,CDM,S5000,HCPCS,250,RC,71285-0007-01,NDC,outpatient,238.75,ML,1537.64,1076.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARDIOPLEGIA SOLN LOW POTASSIUM 4:1 MAINTENANCE,RX-4080156,CDM,S5000,HCPCS,250,RC,72196-0104-01,NDC,outpatient,1000,ML,1042.09,729.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CONCENTRATED DILAUDID 1 MG/ML PCA,RX-4080157,CDM,S5000,HCPCS,250,RC,70004-0303-62,NDC,outpatient,50,ML,212.25,148.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILAUDID 0.2 MG/ML PCA (HYDROMORPHONE),RX-4080159,CDM,S5000,HCPCS,250,RC,70004-0300-62,NDC,outpatient,50,ML,69.63,48.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRISMASATE K 0/CA 3.5 CRRT SOLUTION,RX-4080163,CDM,S5000,HCPCS,250,RC,00000-1053-53,NDC,outpatient,5000,ML,188.44,131.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,99999-0001-52,NDC,outpatient,100,ML,30.84,21.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70004-0231-64,NDC,outpatient,100,ML,109.23,76.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-1202-75,NDC,outpatient,100,ML,258.44,180.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-9202-75,NDC,outpatient,100,ML,251.94,176.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 5 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080169,CDM,S5000,HCPCS,250,RC,99999-0001-55,NDC,outpatient,100,ML,34.55,24.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080170,CDM,S5000,HCPCS,250,RC,99999-0000-03,NDC,outpatient,100,ML,67.18,47.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-22,NDC,outpatient,2,ML,6.33,4.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-12,NDC,outpatient,2,ML,6.33,4.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-01,NDC,outpatient,1,ML,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-21,NDC,outpatient,1,ML,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,70004-0756-12,NDC,outpatient,10,ML,39.83,27.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,99999-0001-50,NDC,outpatient,10,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-01,NDC,outpatient,10,ML,22.61,15.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-10,NDC,outpatient,10,ML,22.61,15.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-01,NDC,outpatient,5,ML,14.35,10.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-10,NDC,outpatient,5,ML,14.35,10.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE-LIDOCAINE 0.3%-1.5% OINT,RX-408020,CDM,S5000,HCPCS,259,RC,00000-0000-03,NDC,outpatient,30,GR,333.75,233.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-15,NDC,outpatient,5,ML,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-05,NDC,outpatient,5,ML,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,71399-2829-01,NDC,outpatient,28,GR,14.21,9.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,00536-1211-95,NDC,outpatient,28,GR,13.84,9.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COCOA BUTTER STICK,RX-4080278,CDM,S5000,HCPCS,259,RC,07570-7011-00,NDC,outpatient,30,ML,4.41,3.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAPSAICIN 0.025 % EX CREAM WRAPPER,RX-4080289,CDM,S5000,HCPCS,259,RC,00536-2525-25,NDC,outpatient,60,GR,10.95,7.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-04,NDC,outpatient,5,GR,24.68,17.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,00168-0357-55,NDC,outpatient,5,GR,29.95,20.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-31,NDC,outpatient,30,GR,87.18,61.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,SH408-0358-01,NDC,outpatient,20,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,99999-0000-54,NDC,outpatient,20,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MULTIVITAMIN CHILDRENS ORAL CHEW WRAPPER,RX-4080360,CDM,S5000,HCPCS,259,RC,80681-0049-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMPHOTERICIN B EYE DROPS 0.2 MG/ML 10 ML BOTTLE,RX-4080376,CDM,S5000,HCPCS,259,RC,SH408-0376-01,NDC,outpatient,10,ML,61.86,43.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 1 MG/ML ORAL SUSPENSION 81 ML FOR ASA DESENSITIZATION,RX-4080380,CDM,S5000,HCPCS,259,RC,SH408-0380-01,NDC,outpatient,81,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFTAZIDIME EYE DROPS 22.5 MG/ML SYRINGE,RX-4080386,CDM,S5000,HCPCS,259,RC,99999-0000-32,NDC,outpatient,1,ML,37.46,26.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN MOUTH WASH 3 MG/ML,RX-4080388,CDM,S5000,HCPCS,259,RC,99999-0000-33,NDC,outpatient,250,ML,10.02,7.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,69623-0801-14,NDC,outpatient,3,ML,35.6,24.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,70092-1135-44,NDC,outpatient,3,ML,49.22,34.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,88888-0926-28,NDC,outpatient,3,ML,22.25,15.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,99999-0003-19,NDC,outpatient,3,ML,14.57,10.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAG SULFATE-GLYCERIN-WATER ENEMA 180 ML,RX-4080412,CDM,S5000,HCPCS,259,RC,00000-0000-02,NDC,outpatient,180,ML,28.04,19.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE ORAL SUSPENSION 1 MG/ML,RX-4080416,CDM,S5000,HCPCS,259,RC,99999-0003-46,NDC,outpatient,12.5,ML,1.93,1.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-08,NDC,outpatient,237,ML,159.26,111.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-37,NDC,outpatient,240,ML,1184.42,829.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,69238-2122-20,NDC,outpatient,20,ML,14.96,10.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-20,NDC,outpatient,20,ML,13.44,9.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,42799-0815-01,NDC,outpatient,237,ML,151.87,106.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-35,NDC,outpatient,20,ML,13.44,9.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-36,NDC,outpatient,5,ML,2.94,2.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0885-16,NDC,outpatient,480,ML,1149.17,804.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-20,NDC,outpatient,20,ML,98.71,69.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,SH408-0423-01,NDC,outpatient,1,ML,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,99999-0001-12,NDC,outpatient,1,ML,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 1 MEQ/ML 1 ML ORAL SYRINGE,RX-4080424,CDM,S5000,HCPCS,259,RC,99999-0001-25,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE-MINERAL OIL-GLYCERIN ENEMA,RX-4080430,CDM,S5000,HCPCS,259,RC,SH408-0430-01,NDC,outpatient,135,ML,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,99999-0001-26,NDC,outpatient,1.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,,,outpatient,1.5,ML,1.92,1.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SPIRONOLACTONE 6 MG/3 ML ORAL SYRINGE,RX-4080435,CDM,S5000,HCPCS,259,RC,99999-0000-28,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFAZOLIN IVPB 2 G IN 100 ML NS PREMIX,RX-4080437,CDM,S5000,HCPCS,250,RC,99999-0000-45,NDC,outpatient,100,ML,47.78,33.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0449-01,NDC,outpatient,2,ML,22.21,15.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0450-01,NDC,outpatient,0.1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN EYE SOLUTION 25 MG/ML,RX-4080451,CDM,S5000,HCPCS,259,RC,SH408-0451-01,NDC,outpatient,20,ML,54.07,37.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VANCOMYCIN EYE SOLUTION 50 MG/ML ,RX-4080452,CDM,S5000,HCPCS,259,RC,SH408-0452-01,NDC,outpatient,20,ML,54.07,37.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,51672-4027-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,76282-0327-01,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,99999-0002-46,NDC,outpatient,0.5,ME,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,51672-4029-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,99999-0002-47,NDC,outpatient,1.25,ME,4.53,3.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0315-25,NDC,outpatient,250,ML,118.35,82.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0533-25,NDC,outpatient,250,ML,140.6,98.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0775-40,NDC,outpatient,250,ML,320.83,224.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-01,NDC,outpatient,250,ML,261.87,183.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0785-40,NDC,outpatient,250,ML,301.03,210.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1652-05,NDC,outpatient,250,ML,216.97,151.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-03,NDC,outpatient,250,ML,261.87,183.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1468-05,NDC,outpatient,250,ML,192.22,134.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,00904-7191-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,48433-0108-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,69374-0932-03,NDC,outpatient,3,ML,45.62,31.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70092-1084-44,NDC,outpatient,5,ML,61.01,42.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-13,NDC,outpatient,3,ML,51.74,36.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-30,NDC,outpatient,3,ML,51.74,36.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70004-0750-09,NDC,outpatient,5,ML,78.06,54.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,00574-0508-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,20555-0019-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,00065-0518-01,NDC,outpatient,3.5,GR,29.43,20.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,10119-0022-39,NDC,outpatient,3.5,GR,30.17,21.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 1 % FOR PLEURODESIS,RX-4080551,CDM,S5000,HCPCS,250,RC,99999-0003-43,NDC,outpatient,50,ML,13.37,9.359,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-01,NDC,outpatient,15,ML,59.41,41.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-29,NDC,outpatient,5,ML,93.68,65.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-11,NDC,outpatient,15,ML,59.41,41.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-09,NDC,outpatient,5,ML,93.68,65.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,00799-0001-04,NDC,outpatient,113,GR,20.12,14.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,10135-0701-04,NDC,outpatient,113,GR,13.58,9.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM 100 MG ADDVANTAGE INFUSION IN D5W 100 ML,RX-4080558,CDM,S5000,HCPCS,250,RC,99999-0000-01,NDC,outpatient,100,ML,48.09,33.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HIV POST EXPOSURE KIT,RX-4080559,CDM,S5000,HCPCS,259,RC,SH408-0559-01,NDC,outpatient,1,UN,1178.97,825.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE 0.125 % IN 100 ML NS NERVE BLOCK CASSETTE,RX-4080570,CDM,S5000,HCPCS,250,RC,61553-0829-48,NDC,outpatient,100,ML,76.93,53.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080589,CDM,S5000,HCPCS,250,RC,99999-0000-04,NDC,outpatient,100,ML,79.95,55.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VEIN GRAFT SOLUTION,RX-4080591,CDM,S5000,HCPCS,250,RC,99999-0000-07,NDC,outpatient,505.67,ML,73.5,51.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLECAINIDE ACETATE 20 MG/ML ORAL SUSP,RX-4080607,CDM,S5000,HCPCS,259,RC,99999-0003-52,NDC,outpatient,2.5,ML,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYOSCYAMINE SULFATE 0.125 MG SL SUBL WRAPPER,RX-4080632,CDM,S5000,HCPCS,259,RC,42192-0338-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-51,NDC,outpatient,60,ML,33.11,23.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-46,NDC,outpatient,60,ML,33.11,23.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0923-41,NDC,outpatient,60,ML,80.91,56.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,10006-0700-28,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM GLUCONATE 500 MG ORAL TABS WRAPPER,RX-4080642,CDM,S5000,HCPCS,259,RC,60258-0172-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GI COCKTAIL SUSPENSION,RX-4080647,CDM,S5000,HCPCS,259,RC,99999-0000-39,NDC,outpatient,55,ML,82.33,57.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARDIOPLEGIA SOLN DEL NIDO,RX-4080676,CDM,S5000,HCPCS,250,RC,99999-0004-39,NDC,outpatient,1052.8,ML,113.01,79.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1512-46,NDC,outpatient,10,ML,20.96,14.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1617-46,NDC,outpatient,10,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IV SOLN MINI-BAG 100 ML,RX-4080711,CDM,S5000,HCPCS,250,RC,00338-0553-18,NDC,outpatient,100,ML,29.37,20.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HYDROCORTISONE ORAL SUSPENSION 2.5 MG/ML COMPOUNDED PRODUCT,RX-4080716,CDM,S5000,HCPCS,259,RC,99999-0000-80,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUDROCORTISONE ACETATE SUSP 0.2 MG/ML,RX-4080718,CDM,S5000,HCPCS,259,RC,99999-0000-81,NDC,outpatient,1,ML,4.96,3.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,74300-0000-71,NDC,outpatient,113,GR,26.15,18.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,62103-0323-02,NDC,outpatient,57,GR,14.72,10.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALOXONE INHALATION KIT - HOSPITAL USE ONLY,RX-4080774,CDM,S5000,HCPCS,259,RC,99999-0000-90,NDC,outpatient,1,UN,110.81,77.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-01,NDC,outpatient,20,ML,230.78,161.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-11,NDC,outpatient,20,ML,230.78,161.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFAZOLIN IVPB 3 G IN 100 ML NS PREMIX,RX-4080801,CDM,S5000,HCPCS,250,RC,99999-0001-10,NDC,outpatient,130,ML,33.43,23.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,70092-1433-50,NDC,outpatient,50,ML,216.36,151.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,99999-0000-98,NDC,outpatient,50,ML,59.06,41.342,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 5 % MOUTHWASH ORAL SUSPENSION,RX-4080811,CDM,S5000,HCPCS,259,RC,99999-0001-06,NDC,outpatient,169,ML,77.47,54.229,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,00045-0166-04,NDC,outpatient,120,ML,28.31,19.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,50580-0170-05,NDC,outpatient,5,ML,1.37,0.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,99999-0001-17,NDC,outpatient,5,ML,1.37,0.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BABY BUTT BALM,RX-4080852,CDM,S5000,HCPCS,259,RC,99999-0001-13,NDC,outpatient,118.7,GR,70.96,49.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAZOLAMIDE 25 MG/ML SUSPENSION,RX-4080874,CDM,S5000,HCPCS,259,RC,99999-0001-21,NDC,outpatient,5,ML,10.93,7.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,99999-0002-20,NDC,outpatient,15,ML,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00005-4344-62,NDC,outpatient,15,ML,2.09,1.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-30,NDC,outpatient,15,ML,2.32,1.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-59,NDC,outpatient,15,ML,7.68,5.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,69618-0008-58,NDC,outpatient,15,ML,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-15,NDC,outpatient,15,ML,2.32,1.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-61,NDC,outpatient,15,ML,7.68,5.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,38779-1284-08,NDC,outpatient,8,ML,2.35,1.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-02,NDC,outpatient,8,ML,9.33,6.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-08,NDC,outpatient,8,ML,47.67,33.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,49452-3081-02,NDC,outpatient,8,ML,2.35,1.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0170-05,NDC,outpatient,5,ML,35.56,24.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-01,NDC,outpatient,15,ML,169.35,118.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-16,NDC,outpatient,15,ML,169.35,118.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-01,NDC,outpatient,5,ML,79.73,55.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-06,NDC,outpatient,5,ML,79.73,55.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,43066-0007-10,NDC,outpatient,5,ML,8.46,5.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-05,NDC,outpatient,5,ML,7.05,4.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,67457-0228-02,NDC,outpatient,5,ML,6.84,4.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-05,NDC,outpatient,10,ML,22.61,15.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-06,NDC,outpatient,10,ML,22.61,15.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-02,NDC,outpatient,5,ML,7.05,4.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-01,NDC,outpatient,5,ML,24.17,16.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-10,NDC,outpatient,5,ML,24.17,16.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-01,NDC,outpatient,5,ML,10.46,7.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,25021-0662-05,NDC,outpatient,5,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0225-05,NDC,outpatient,5,ML,9.23,6.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-10,NDC,outpatient,5,ML,10.46,7.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0226-10,NDC,outpatient,10,ML,18.46,12.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,66794-0228-41,NDC,outpatient,5,ML,6.84,4.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMIODARONE ORAL SUSPENSION 40 MG/ML,RX-4080970,CDM,S5000,HCPCS,259,RC,99999-0001-63,NDC,outpatient,10,ML,2.04,1.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 100 MG/100 ML IN D5W PF PREMIX,RX-4081012,CDM,S5000,HCPCS,250,RC,99999-0000-99,NDC,outpatient,100,ML,312.37,218.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-10,NDC,outpatient,10,ML,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-07,NDC,outpatient,10,ML,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,42023-0243-01,NDC,outpatient,10,ML,42.55,29.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,99999-0000-87,NDC,outpatient,100,ML,34.01,23.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DILTIAZEM 100 MG IN 100 ML NS BATCHED INFUSION,RX-4081050,CDM,S5000,HCPCS,250,RC,99999-0002-64,NDC,outpatient,100,ML,56.68,39.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
URSODIOL 50 MG/ML ORAL SUSPENSION,RX-4081064,CDM,S5000,HCPCS,259,RC,99999-0002-69,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPRENORPHINE-NALOXONE (SUBOXONE) SL FILM 8 MG-2 MG KIT,RX-4081171,CDM,S5000,HCPCS,259,RC,99999-0003-16,NDC,outpatient,1,UN,142.33,99.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-05,NDC,outpatient,5,ML,19.63,13.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-15,NDC,outpatient,5,ML,19.63,13.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-11,NDC,outpatient,5,ML,17.92,12.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-34,NDC,outpatient,5,ML,17.92,12.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,76329-3390-01,NDC,outpatient,5,ML,27.15,19.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,63323-0208-05,NDC,outpatient,5,ML,7.41,5.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,12.64,8.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,12.64,8.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 100 MG/100 ML IN NS PF PREMIX,RX-4081195,CDM,S5000,HCPCS,250,RC,99999-0003-26,NDC,outpatient,100,ML,312.37,218.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANTOPRAZOLE 80 MG/100 ML INFUSION PREMIX,RX-4081208,CDM,S5000,HCPCS,250,RC,99999-0000-77,NDC,outpatient,100,ML,36.56,25.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-10,NDC,outpatient,200,ML,242.06,169.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-01,NDC,outpatient,200,ML,242.06,169.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 3 % IV ONCE,RX-4081432,CDM,S5000,HCPCS,250,RC,99999-0003-86,NDC,outpatient,100,ML,18.06,12.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FAMOTIDINE IN NACL 20-0.9 MG/10 ML-% IV SOSY,RX-4081444,CDM,S5000,HCPCS,250,RC,99999-0003-96,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM HYALURONATE 10 MG/ML IO SOLN WRAPPER,RX-4081458,CDM,S5000,HCPCS,250,RC,05047-4508-38,NDC,outpatient,0.4,ML,397.92,278.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV *BATCHED*,RX-4081542,CDM,S5000,HCPCS,250,RC,99999-0004-35,NDC,outpatient,50,ML,157.29,110.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,99999-0004-53,NDC,outpatient,100,ML,48.85,34.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,70092-1518-75,NDC,outpatient,100,ML,209.09,146.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,0.5,UN,4.12,2.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,0.5,UN,2.9,2.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,0.5,UN,1,0.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHADONE 10 MG TABLET DISCHARGE KIT,RX-4081610,CDM,S5000,HCPCS,259,RC,99999-0004-50,NDC,outpatient,1,UN,6.15,4.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRISMASATE K 4/CA 2.5 CRRT SOLUTION,RX-40840045,CDM,S5000,HCPCS,250,RC,SH408-4045-01,NDC,outpatient,5000,ML,188.44,131.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRISMASATE K 2/CA 0 CRRT SOLUTION,RX-40840046,CDM,S5000,HCPCS,250,RC,SH408-4046-01,NDC,outpatient,5000,ML,188.44,131.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0011-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0012-66,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,63629-2364-01,NDC,outpatient,1,UN,6.03,4.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,47335-0835-83,NDC,outpatient,1,UN,5.27,3.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,S5000,HCPCS,259,RC,00597-0087-17,NDC,outpatient,12.9,GR,1940.98,1358.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENTECAVIR 0.5 MG ORAL TABS,RX-41147,CDM,S5000,HCPCS,259,RC,00003-1611-12,NDC,outpatient,1,UN,197.48,138.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENTECAVIR 1 MG ORAL TABS,RX-41148,CDM,S5000,HCPCS,259,RC,65862-0842-30,NDC,outpatient,1,UN,8.95,6.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-98,NDC,outpatient,1,UN,50.62,35.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-47,NDC,outpatient,1,UN,21.37,14.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-16,NDC,outpatient,1,UN,50.62,35.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-11,NDC,outpatient,1,UN,21.37,14.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,49483-0687-03,NDC,outpatient,1,UN,4.45,3.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,65862-0936-30,NDC,outpatient,1,UN,5.24,3.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,99999-0002-52,NDC,outpatient,10,ML,6.37,4.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,52817-0830-04,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-01,NDC,outpatient,0.5,ML,58.03,40.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-02,NDC,outpatient,0.5,ML,64.31,45.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-05,NDC,outpatient,0.5,ML,58.03,40.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-00,NDC,outpatient,0.5,ML,58.19,40.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OMEGA-3-ACID ETHYL ESTERS 1 G ORAL CAPS,RX-41822,CDM,S5000,HCPCS,259,RC,64380-0761-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,64380-0789-32,NDC,outpatient,35.44,GR,61.67,43.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,65162-0918-38,NDC,outpatient,35.44,GR,50,35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,63739-0072-33,NDC,outpatient,1,UN,2.21,1.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,00904-6671-04,NDC,outpatient,1,UN,2.21,1.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METRONIDAZOLE 1 % EX GEL,RX-41899,CDM,S5000,HCPCS,259,RC,51672-4215-03,NDC,outpatient,60,GR,258.99,181.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AVEENO SOOTHING BATH TREATMENT EX PACK,RX-41904,CDM,S5000,HCPCS,259,RC,08137-0036-40,NDC,outpatient,1,UN,2.74,1.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-11,NDC,outpatient,1,UN,11.47,8.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-15,NDC,outpatient,1,UN,11.47,8.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,70010-0028-03,NDC,outpatient,1,UN,6.31,4.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,00054-0622-63,NDC,outpatient,5,ML,3.5,2.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,99999-0003-12,NDC,outpatient,5,ML,5.06,3.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-01,NDC,outpatient,1,UN,1.96,1.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,50228-0350-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-11,NDC,outpatient,1,UN,1.96,1.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,72205-0012-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00071-1013-41,NDC,outpatient,1,UN,45.77,32.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00904-6992-61,NDC,outpatient,1,UN,2.3,1.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00071-1014-41,NDC,outpatient,1,UN,45.77,32.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-01,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,62332-0121-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00904-7000-61,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-11,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,00904-7001-61,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,69238-1313-09,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,62332-0122-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00904-7002-61,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00071-1016-41,NDC,outpatient,1,UN,45.77,32.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,S5000,HCPCS,250,RC,42023-0113-10,NDC,outpatient,20,ML,41.57,29.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,S5000,HCPCS,250,RC,42023-0115-10,NDC,outpatient,5,ML,53.45,37.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-01,NDC,outpatient,10,ML,23.23,16.261,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-10,NDC,outpatient,10,ML,23.23,16.261,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,70756-0201-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-11,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-15,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-01,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,00781-1487-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-11,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,00054-0057-46,NDC,outpatient,60,ML,612.5,428.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,99999-0004-03,NDC,outpatient,2.5,ML,25.53,17.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-11,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-01,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,S5000,HCPCS,259,RC,76329-6300-05,NDC,outpatient,4,ML,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMMONIA AROMATIC IN INHA,RX-439,CDM,S5000,HCPCS,259,RC,67777-0251-01,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00054-8496-19,NDC,outpatient,1,UN,7.46,5.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00555-0484-02,NDC,outpatient,1,UN,5.35,3.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-01,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-11,NDC,outpatient,1,UN,1.54,1.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-20,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-01,NDC,outpatient,1,UN,1.54,1.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-01,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-01,NDC,outpatient,1,UN,1.67,1.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-11,NDC,outpatient,1,UN,1.67,1.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,00074-4552-11,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-20,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-20,NDC,outpatient,1,UN,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-01,NDC,outpatient,1,UN,2.04,1.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-01,NDC,outpatient,1,UN,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-11,NDC,outpatient,1,UN,2.04,1.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-20,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,00074-6624-11,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-01,NDC,outpatient,1,UN,3.14,2.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-20,NDC,outpatient,1,UN,3.14,2.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,60687-0530-01,NDC,outpatient,1,UN,2.51,1.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,00074-7069-11,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00527-6004-80,NDC,outpatient,50,ML,75.88,53.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,60432-0465-51,NDC,outpatient,50,ML,131.72,92.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00054-3505-47,NDC,outpatient,50,ML,107.03,74.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 0.5 % IJ SOLN,RX-4451,CDM,S5000,HCPCS,250,RC,63323-0484-57,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-02,NDC,outpatient,50,ML,8.23,5.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-16,NDC,outpatient,20,ML,4.63,3.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-17,NDC,outpatient,50,ML,8.23,5.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-01,NDC,outpatient,20,ML,4.63,3.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0254-10,NDC,outpatient,10,ML,3.76,2.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0255-20,NDC,outpatient,20,ML,4.22,2.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-17,NDC,outpatient,10,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-01,NDC,outpatient,2,ML,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-02,NDC,outpatient,20,ML,18.2,12.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-26,NDC,outpatient,20,ML,8.02,5.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-01,NDC,outpatient,20,ML,5.14,3.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-16,NDC,outpatient,20,ML,5.14,3.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-02,NDC,outpatient,2,ML,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-01,NDC,outpatient,10,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-27,NDC,outpatient,20,ML,18.2,12.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,16714-0298-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,65862-0016-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,51862-0321-01,NDC,outpatient,1,UN,3.45,2.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,00093-2178-01,NDC,outpatient,1,UN,3.21,2.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,59762-1207-01,NDC,outpatient,1,UN,3.28,2.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN 500 MG ORAL CAPS,RX-451,CDM,S5000,HCPCS,259,RC,16714-0299-03,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LITHIUM CARBONATE 150 MG ORAL CAPS,RX-4528,CDM,S5000,HCPCS,259,RC,00054-8526-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,00054-8527-25,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,31722-0545-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00093-4155-79,NDC,outpatient,80,ML,14.6,10.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00143-9889-15,NDC,outpatient,150,ML,20.7,14.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,99999-0002-83,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-20,NDC,outpatient,1,UN,3,2.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-01,NDC,outpatient,1,UN,3,2.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-01,NDC,outpatient,1,UN,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-11,NDC,outpatient,1,UN,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00121-0770-01,NDC,outpatient,30,ML,33.11,23.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00054-3532-44,NDC,outpatient,30,ML,100.26,70.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,99999-0001-38,NDC,outpatient,1,ML,3.55,2.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00093-3425-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,13107-0083-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,69315-0904-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00904-6008-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00093-3426-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOXAPINE SUCCINATE 25 MG ORAL CAPS,RX-4600,CDM,S5000,HCPCS,259,RC,00591-0371-01,NDC,outpatient,1,UN,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LOXAPINE SUCCINATE 5 MG ORAL CAPS,RX-4601,CDM,S5000,HCPCS,259,RC,00591-0369-01,NDC,outpatient,1,UN,1.31,0.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MAGNESIUM CITRATE 1.745 GM/30ML ORAL SOLN,RX-4711,CDM,S5000,HCPCS,259,RC,70677-1111-01,NDC,outpatient,296,ML,7.91,5.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-02,NDC,outpatient,250,ML,79.42,55.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-13,NDC,outpatient,500,ML,93.88,65.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-03,NDC,outpatient,500,ML,80.53,56.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-03,NDC,outpatient,500,ML,93.88,65.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEDROXYPROGESTERONE ACETATE 10 MG ORAL TABS,RX-4854,CDM,S5000,HCPCS,259,RC,00555-0779-02,NDC,outpatient,1,UN,1.07,0.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MEDROXYPROGESTERONE ACETATE 2.5 MG ORAL TABS,RX-4855,CDM,S5000,HCPCS,259,RC,00555-0872-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-23,NDC,outpatient,1,UN,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-62,NDC,outpatient,1,UN,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00054-0710-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-23,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-62,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHAZOLAMIDE 50 MG ORAL TABS,RX-4962,CDM,S5000,HCPCS,259,RC,00574-0791-01,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,00904-7057-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,31722-0533-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,76385-0123-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-11,NDC,outpatient,1,UN,5.13,3.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-21,NDC,outpatient,1,UN,5.13,3.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,00406-1144-01,NDC,outpatient,1,UN,1.43,1.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPREDNISOLONE 16 MG ORAL TABS,RX-4992,CDM,S5000,HCPCS,259,RC,59762-0050-01,NDC,outpatient,1,UN,8.54,5.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,00904-6914-61,NDC,outpatient,1,UN,4.37,3.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-01,NDC,outpatient,1,UN,4.95,3.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-11,NDC,outpatient,1,UN,4.95,3.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-01,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-11,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METRONIDAZOLE 250 MG ORAL TABS,RX-5015,CDM,S5000,HCPCS,259,RC,00904-7156-61,NDC,outpatient,1,UN,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-11,NDC,outpatient,1,UN,2.17,1.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,29300-0227-01,NDC,outpatient,1,UN,1.76,1.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-01,NDC,outpatient,1,UN,2.17,1.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,S5000,HCPCS,259,RC,61269-0735-14,NDC,outpatient,14,GR,7.54,5.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,99999-0002-15,NDC,outpatient,30,ML,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,48433-0202-30,NDC,outpatient,30,ML,5.08,3.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINOCYCLINE HCL 50 MG ORAL CAPS,RX-5111,CDM,S5000,HCPCS,259,RC,00591-5694-60,NDC,outpatient,1,UN,1.26,0.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-11,NDC,outpatient,1,UN,2.48,1.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-01,NDC,outpatient,1,UN,2.48,1.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,00591-5642-01,NDC,outpatient,1,UN,1.01,0.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-11,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-01,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-05,NDC,outpatient,5,ML,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-59,NDC,outpatient,5,ML,4.7,3.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,99999-0002-19,NDC,outpatient,5,ML,2.14,1.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00054-0237-49,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-62,NDC,outpatient,5,ML,4.7,3.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-94,NDC,outpatient,5,ML,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-24,NDC,outpatient,1,UN,3.2,2.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-25,NDC,outpatient,1,UN,2.1,1.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MORPHINE SULFATE 10 MG RE SUPP,RX-5180,CDM,S5000,HCPCS,259,RC,00574-7112-12,NDC,outpatient,1,UN,19.66,13.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-95,NDC,outpatient,1,UN,11.38,7.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-25,NDC,outpatient,1,UN,11.38,7.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,00904-7071-07,NDC,outpatient,1,UN,9.11,6.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,69097-0868-07,NDC,outpatient,1,UN,1.13,0.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,65162-0188-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,65162-0189-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65862-0522-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65162-0190-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,63739-0403-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-05,NDC,outpatient,1,UN,3.09,2.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-07,NDC,outpatient,1,UN,3.09,2.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,S5000,HCPCS,259,RC,24208-0790-62,NDC,outpatient,10,ML,150.86,105.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIACIN 100 MG ORAL TABS,RX-5539,CDM,S5000,HCPCS,259,RC,80681-0057-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NIFEDIPINE 10 MG ORAL CAPS,RX-5558,CDM,S5000,HCPCS,259,RC,23155-0194-01,NDC,outpatient,1,UN,1.98,1.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAPS,RX-5595,CDM,S5000,HCPCS,259,RC,57664-0232-88,NDC,outpatient,1,UN,3.41,2.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,68462-0638-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,72888-0138-01,NDC,outpatient,1,UN,1.43,1.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,00071-0417-24,NDC,outpatient,1,UN,3.05,2.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-35,NDC,outpatient,0.75,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-25,NDC,outpatient,0.75,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-45,NDC,outpatient,0.75,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-11,NDC,outpatient,0.75,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,S5000,HCPCS,259,RC,00281-0326-08,NDC,outpatient,1,GR,9.96,6.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-01,NDC,outpatient,1,UN,1.89,1.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-11,NDC,outpatient,1,UN,1.89,1.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,00713-0678-15,NDC,outpatient,15,GR,53.4,37.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,45802-0059-35,NDC,outpatient,15,GR,17.03,11.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,51672-1289-01,NDC,outpatient,15,GR,18.83,13.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,45802-0048-35,NDC,outpatient,15,GR,13.29,9.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,00472-0166-15,NDC,outpatient,15,GR,61.35,42.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-70,NDC,outpatient,5,ML,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,99999-0003-91,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-05,NDC,outpatient,5,ML,4.74,3.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-1045-16,NDC,outpatient,5,ML,4.21,2.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-10,NDC,outpatient,5,ML,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-00,NDC,outpatient,5,ML,4.74,3.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,S5000,HCPCS,259,RC,51672-1263-01,NDC,outpatient,15,GR,15.02,10.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,S5000,HCPCS,259,RC,51672-1272-01,NDC,outpatient,15,GR,22.37,15.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ORA-PLUS ORAL LIQD,RX-5851,CDM,S5000,HCPCS,259,RC,00574-0303-16,NDC,outpatient,473,ML,130.96,91.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ORA-SWEET SF ORAL SYRP,RX-5853,CDM,S5000,HCPCS,259,RC,00574-0302-16,NDC,outpatient,473,ML,130.96,91.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-11,NDC,outpatient,1,UN,8.63,6.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-01,NDC,outpatient,1,UN,8.63,6.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,00228-2067-10,NDC,outpatient,1,UN,3.24,2.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-11,NDC,outpatient,1,UN,9.09,6.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-01,NDC,outpatient,1,UN,9.09,6.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-11,NDC,outpatient,1,UN,1.85,1.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-01,NDC,outpatient,1,UN,1.85,1.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,00904-7027-61,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-62,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-23,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-05,NDC,outpatient,2,ML,78.96,55.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-01,NDC,outpatient,2,ML,69.91,48.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-10,NDC,outpatient,2,ML,69.91,48.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,00517-4002-25,NDC,outpatient,2,ML,103.84,72.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-07,NDC,outpatient,2,ML,78.96,55.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-94,NDC,outpatient,1,UN,142.02,99.414,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-95,NDC,outpatient,1,UN,142.02,99.414,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,99999-0002-88,NDC,outpatient,10,ML,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,00093-4127-73,NDC,outpatient,100,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENICILLIN V POTASSIUM 250 MG ORAL TABS,RX-6092,CDM,S5000,HCPCS,259,RC,57237-0040-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00143-9836-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00093-1174-01,NDC,outpatient,1,UN,1.67,1.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PERPHENAZINE 2 MG ORAL TABS,RX-6157,CDM,S5000,HCPCS,259,RC,00904-6599-61,NDC,outpatient,1,UN,2.75,1.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PERPHENAZINE 8 MG ORAL TABS,RX-6159,CDM,S5000,HCPCS,259,RC,00904-6601-61,NDC,outpatient,1,UN,5.02,3.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENAZOPYRIDINE HCL 100 MG ORAL TABS,RX-6193,CDM,S5000,HCPCS,259,RC,65162-0681-10,NDC,outpatient,1,UN,1.61,1.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-05,NDC,outpatient,5,ML,7.01,4.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,54932-0501-81,NDC,outpatient,473,ML,75.78,53.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,13517-0107-16,NDC,outpatient,473,ML,307.31,215.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-50,NDC,outpatient,5,ML,7.01,4.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,99999-0002-30,NDC,outpatient,5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,16571-0675-16,NDC,outpatient,473,ML,82.09,57.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,16571-0673-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,00904-6575-61,NDC,outpatient,1,UN,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,S5000,HCPCS,259,RC,00225-0800-47,NDC,outpatient,15,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,S5000,HCPCS,259,RC,00225-0805-47,NDC,outpatient,15,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,S5000,HCPCS,259,RC,00225-0810-47,NDC,outpatient,15,ML,15.09,10.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYLEPHRINE HCL 2.5 % OP SOLN,RX-6246,CDM,S5000,HCPCS,259,RC,70756-0629-25,NDC,outpatient,2,ML,146.94,102.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-62,NDC,outpatient,4,ML,13.48,9.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-66,NDC,outpatient,4,ML,13.48,9.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,57664-0808-88,NDC,outpatient,1,UN,1.19,0.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,65862-0692-01,NDC,outpatient,1,UN,1.74,1.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,S5000,HCPCS,259,RC,61314-0203-15,NDC,outpatient,15,ML,342.03,239.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,61314-0204-15,NDC,outpatient,15,ML,351.44,246.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,70069-0191-01,NDC,outpatient,15,ML,140.98,98.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,S5000,HCPCS,259,RC,61314-0206-15,NDC,outpatient,15,ML,326.81,228.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PIROXICAM 10 MG ORAL CAPS,RX-6310,CDM,S5000,HCPCS,259,RC,42571-0176-01,NDC,outpatient,1,UN,3.12,2.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,00087-0402-03,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,99999-0001-68,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,S5000,HCPCS,250,RC,55150-0234-10,NDC,outpatient,1,UN,16.13,11.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-01,NDC,outpatient,20,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-11,NDC,outpatient,20,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,51754-2001-04,NDC,outpatient,20,ML,18.07,12.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POVIDONE-IODINE 10 % EX SOLN,RX-6458,CDM,S5000,HCPCS,259,RC,52380-1905-00,NDC,outpatient,59,ML,4.73,3.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-01,NDC,outpatient,1,UN,6.21,4.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-20,NDC,outpatient,1,UN,6.21,4.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-01,NDC,outpatient,1,UN,5.34,3.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-11,NDC,outpatient,1,UN,5.34,3.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-01,NDC,outpatient,1,UN,14.76,10.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-20,NDC,outpatient,1,UN,14.76,10.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,11980-0180-05,NDC,outpatient,5,ML,534.23,373.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,60758-0119-05,NDC,outpatient,5,ML,106.58,74.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,61314-0637-05,NDC,outpatient,5,ML,113.48,79.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-4741-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-8739-25,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,59651-0484-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00054-0017-20,NDC,outpatient,1,UN,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00904-6923-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00603-5338-21,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-8740-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-4742-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00054-0018-20,NDC,outpatient,1,UN,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,59746-0175-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,64380-0785-07,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00904-7127-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,00054-8724-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,59651-0489-01,NDC,outpatient,1,UN,1.61,1.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-20,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-25,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,10135-0779-01,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASCORBIC ACID 500 MG/ML IJ SOLN,RX-654,CDM,S5000,HCPCS,250,RC,67157-0101-51,NDC,outpatient,50,ML,1099.15,769.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-15,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-11,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROBENECID 500 MG ORAL TABS,RX-6561,CDM,S5000,HCPCS,259,RC,00591-5347-01,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,27808-0065-02,NDC,outpatient,2.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,99999-0002-39,NDC,outpatient,5,ML,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,24208-0730-06,NDC,outpatient,15,ML,110.61,77.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,61314-0016-01,NDC,outpatient,15,ML,111.21,77.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-05,NDC,outpatient,5,ML,10.08,7.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00054-3727-63,NDC,outpatient,500,ML,209.15,146.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-40,NDC,outpatient,5,ML,10.08,7.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,69238-2077-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,00378-0182-01,NDC,outpatient,1,UN,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-11,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,00603-5484-21,NDC,outpatient,1,UN,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-01,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,67253-0651-10,NDC,outpatient,1,UN,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,00228-2348-10,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-5053-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-6990-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,70954-0484-10,NDC,outpatient,1,UN,17.43,12.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,10135-0735-60,NDC,outpatient,1,UN,15.09,10.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,33342-0447-11,NDC,outpatient,1,UN,19.28,13.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
QUININE SULFATE 324 MG ORAL CAPS,RX-6781,CDM,S5000,HCPCS,259,RC,50742-0238-30,NDC,outpatient,1,UN,2.82,1.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,63739-0434-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,66553-0002-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-80,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,66553-0001-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,57896-0901-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 325 MG ORAL TBEC,RX-685,CDM,S5000,HCPCS,259,RC,57896-0921-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00904-6783-70,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00536-1234-41,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,63739-0212-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ASPIRIN 300 MG RE SUPP,RX-693,CDM,S5000,HCPCS,259,RC,00574-7034-12,NDC,outpatient,1,UN,4.58,3.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN DETEMIR 100 UNIT/ML SC SOLN,RX-70261,CDM,S5000,HCPCS,259,RC,00169-3687-12,NDC,outpatient,10,ML,388.27,271.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-99,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,00904-3865-75,NDC,outpatient,44,ML,3.33,2.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,49348-0356-25,NDC,outpatient,44,ML,5.88,4.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAMADOL HCL ER 200 MG ORAL TB24,RX-70353,CDM,S5000,HCPCS,259,RC,68180-0698-06,NDC,outpatient,1,UN,19.84,13.888,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-11,NDC,outpatient,1,UN,5.07,3.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-15,NDC,outpatient,1,UN,5.07,3.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,68462-0319-60,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-11,NDC,outpatient,1,UN,5.08,3.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-21,NDC,outpatient,1,UN,5.08,3.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LUBIPROSTONE 24 MCG ORAL CAPS,RX-70472,CDM,S5000,HCPCS,259,RC,00254-3029-02,NDC,outpatient,1,UN,4.45,3.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00536-1183-99,NDC,outpatient,9.9,ML,45.6,31.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00054-3270-99,NDC,outpatient,16,GR,32.12,22.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,S5000,HCPCS,259,RC,00002-7511-01,NDC,outpatient,10,ML,211.82,148.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-50,NDC,outpatient,50,GR,55.18,38.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,61570-0131-55,NDC,outpatient,50,GR,30.49,21.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-40,NDC,outpatient,400,GR,153.08,107.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,49348-0188-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,00904-7206-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,69618-0033-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,00536-1303-75,NDC,outpatient,0.3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,49348-0740-27,NDC,outpatient,0.6,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,99999-0003-45,NDC,outpatient,0.6,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-73,NDC,outpatient,20,ML,14.91,10.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-83,NDC,outpatient,20,ML,14.91,10.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-00,NDC,outpatient,100,ML,36.05,25.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-04,NDC,outpatient,100,ML,36.05,25.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-02,NDC,outpatient,5,ML,19.45,13.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-14,NDC,outpatient,10,ML,57.94,40.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-24,NDC,outpatient,10,ML,57.94,40.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-12,NDC,outpatient,5,ML,19.45,13.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,63323-0083-05,NDC,outpatient,5,ML,33.6,23.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-14,NDC,outpatient,50,ML,85.67,59.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-24,NDC,outpatient,50,ML,85.67,59.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-24,NDC,outpatient,10,ML,71.78,50.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-14,NDC,outpatient,50,ML,35.83,25.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-14,NDC,outpatient,50,ML,54.74,38.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-24,NDC,outpatient,50,ML,54.74,38.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-04,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,63323-0089-50,NDC,outpatient,50,ML,24.7,17.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-22,NDC,outpatient,50,ML,35.83,25.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,76329-3352-01,NDC,outpatient,50,ML,66.31,46.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-14,NDC,outpatient,10,ML,71.78,50.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-01,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,69374-0214-50,NDC,outpatient,50,ML,48.95,34.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM BICARBONATE 650 MG ORAL TABS,RX-7313,CDM,S5000,HCPCS,259,RC,66553-0008-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,99999-0004-11,NDC,outpatient,250,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,00338-0054-03,NDC,outpatient,500,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-61,NDC,outpatient,100,ML,55.63,38.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-02,NDC,outpatient,100,ML,55.63,38.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-03,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-33,NDC,outpatient,3,ML,1.13,0.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,76204-0300-03,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,50190-0142-63,NDC,outpatient,4,ML,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,00487-9003-30,NDC,outpatient,4,ML,2.44,1.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,00223-1760-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-25,NDC,outpatient,1,UN,1.03,0.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-10,NDC,outpatient,1,UN,1.03,0.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,S5000,HCPCS,259,RC,24208-0385-55,NDC,outpatient,3.5,GR,68.8,48.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,S5000,HCPCS,259,RC,00536-1254-94,NDC,outpatient,15,ML,15.76,11.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM HYPOCHLORITE 5 % SOLN,RX-7343,CDM,S5000,HCPCS,259,RC,SH000-4343-01,NDC,outpatient,4000,ML,17.8,12.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM POLYSTYRENE SULFONATE ORAL POWD,RX-7356,CDM,S5000,HCPCS,259,RC,11534-0166-15,NDC,outpatient,15,GR,55.61,38.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFACETAMIDE SODIUM 10 % OP SOLN,RX-7359,CDM,S5000,HCPCS,259,RC,24208-0670-04,NDC,outpatient,15,ML,213.67,149.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,S5000,HCPCS,259,RC,60219-1749-03,NDC,outpatient,5,ML,103.02,72.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,63629-1061-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,00904-6927-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-24,NDC,outpatient,50,ML,8.74,6.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-50,NDC,outpatient,50,ML,8.74,6.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-01,NDC,outpatient,10,ML,4.79,3.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-25,NDC,outpatient,10,ML,4.79,3.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-10,NDC,outpatient,10,ML,4.22,2.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0003-47,NDC,outpatient,3000,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0004-04,NDC,outpatient,1000,ML,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
STOMAHESIVE PASTE PSTE,RX-7493,CDM,S5000,HCPCS,259,RC,68455-0106-90,NDC,outpatient,56.7,GR,38.61,27.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFADIAZINE 500 MG ORAL TABS,RX-7554,CDM,S5000,HCPCS,259,RC,42806-0757-60,NDC,outpatient,1,UN,65.91,46.137,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-10,NDC,outpatient,10,ML,27.51,19.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-01,NDC,outpatient,10,ML,28.26,19.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-03,NDC,outpatient,10,ML,28.26,19.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-01,NDC,outpatient,10,ML,27.51,19.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-15,NDC,outpatient,1,UN,1.12,0.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-11,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-11,NDC,outpatient,1,UN,1.12,0.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-65,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFASALAZINE 500 MG ORAL TABS,RX-7562,CDM,S5000,HCPCS,259,RC,59762-5000-05,NDC,outpatient,1,UN,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,59762-0104-05,NDC,outpatient,1,UN,1.47,1.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,00013-0102-50,NDC,outpatient,1,UN,8.65,6.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VARENICLINE TARTRATE 0.5 MG ORAL TABS,RX-76444,CDM,S5000,HCPCS,259,RC,49884-0155-76,NDC,outpatient,1,UN,6.79,4.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-11,NDC,outpatient,1,UN,43.68,30.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-21,NDC,outpatient,1,UN,43.68,30.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,S5000,HCPCS,259,RC,24208-0539-20,NDC,outpatient,1,UN,349.11,244.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,00436-0672-16,NDC,outpatient,473,ML,52.63,36.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,39328-0064-12,NDC,outpatient,473,ML,44.21,30.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-15,NDC,outpatient,15,ML,19.43,13.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-40,NDC,outpatient,15,ML,19.43,13.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-16,NDC,outpatient,7.5,ML,2.05,1.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-01,NDC,outpatient,15,ML,8.75,6.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-50,NDC,outpatient,15,ML,8.75,6.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-15,NDC,outpatient,15,ML,3.54,2.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN D3 25 MCG (1000 UT) ORAL TABS,RX-76997,CDM,S5000,HCPCS,259,RC,20555-0033-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TANNIC ACID POWD,RX-7715,CDM,S5000,HCPCS,259,RC,,,outpatient,20,GR,9.26,6.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-01,NDC,outpatient,10,ML,230.25,161.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-05,NDC,outpatient,10,ML,230.25,161.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-28,NDC,outpatient,1,UN,78.54,54.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-01,NDC,outpatient,1,UN,78.54,54.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-01,NDC,outpatient,1,UN,78.54,54.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-31,NDC,outpatient,1,UN,78.53,54.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-28,NDC,outpatient,1,UN,78.54,54.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,00121-1576-10,NDC,outpatient,10,ML,13.35,9.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,99999-0001-27,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,68682-0920-64,NDC,outpatient,15,ML,325.88,228.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,00065-0741-14,NDC,outpatient,4,ML,54.08,37.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TETRACYCLINE HCL 250 MG ORAL CAPS,RX-7796,CDM,S5000,HCPCS,259,RC,23155-0766-01,NDC,outpatient,1,UN,2.97,2.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-15,NDC,outpatient,15,ML,35.25,24.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-40,NDC,outpatient,15,ML,35.25,24.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-44,NDC,outpatient,15,ML,40.12,28.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-71,NDC,outpatient,15,ML,40.12,28.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THERA ORAL TABS,RX-7825,CDM,S5000,HCPCS,259,RC,00904-0539-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THERA-DERM EX LOTN,RX-7831,CDM,S5000,HCPCS,259,RC,00904-4299-09,NDC,outpatient,236,ML,8.41,5.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MESALAMINE 1.2 G ORAL TBEC,RX-78310,CDM,S5000,HCPCS,259,RC,00527-3012-48,NDC,outpatient,1,UN,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,49348-0011-34,NDC,outpatient,177,ML,6.31,4.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00395-0413-96,NDC,outpatient,177,ML,11.82,8.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00904-2533-21,NDC,outpatient,177,ML,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-05,NDC,outpatient,5,ML,11.06,7.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-40,NDC,outpatient,5,ML,11.06,7.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,99999-0002-04,NDC,outpatient,5,ML,1.78,1.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THYROID 30 MG ORAL TABS,RX-7944,CDM,S5000,HCPCS,259,RC,62559-0741-01,NDC,outpatient,1,UN,2.88,2.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,00904-0722-36,NDC,outpatient,14.18,GR,4.36,3.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,49348-0155-29,NDC,outpatient,15,GR,8.88,6.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,S5000,HCPCS,259,RC,00536-1329-26,NDC,outpatient,45,GR,7.41,5.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-15,NDC,outpatient,1,UN,1.77,1.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,68382-0807-01,NDC,outpatient,1,UN,1.31,0.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-11,NDC,outpatient,1,UN,1.77,1.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,50111-0560-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,68382-0805-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,00904-6868-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,60505-2653-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,S5000,HCPCS,259,RC,00168-0003-80,NDC,outpatient,80,GR,21.72,15.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,45802-0064-36,NDC,outpatient,80,GR,11.04,7.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,67877-0251-80,NDC,outpatient,80,GR,39.16,27.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,S5000,HCPCS,259,RC,45802-0065-35,NDC,outpatient,15,GR,20.23,14.161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN,RX-8115,CDM,S5000,HCPCS,259,RC,70752-0129-05,NDC,outpatient,60,ML,126.03,88.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,60432-0561-61,NDC,outpatient,60,ML,66.75,46.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,00713-0676-53,NDC,outpatient,60,ML,73.43,51.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.025 % EX OINT,RX-8117,CDM,S5000,HCPCS,259,RC,00168-0005-80,NDC,outpatient,80,GR,21.01,14.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00168-0006-80,NDC,outpatient,80,GR,22.79,15.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00713-0228-80,NDC,outpatient,80,GR,37.03,25.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,45802-0055-36,NDC,outpatient,80,GR,19.58,13.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,51672-1284-08,NDC,outpatient,80,GR,43.44,30.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,S5000,HCPCS,259,RC,33342-0332-15,NDC,outpatient,15,GR,28.77,20.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,S5000,HCPCS,259,RC,64980-0320-05,NDC,outpatient,5,GR,139.78,97.846,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIVALPROEX SODIUM ER 500 MG ORAL TB24,RX-81426,CDM,S5000,HCPCS,259,RC,00904-7182-45,NDC,outpatient,1,UN,11.3,7.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00310-7372-20,NDC,outpatient,10.2,GR,973.53,681.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00186-0372-28,NDC,outpatient,6.9,GR,250.86,175.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00186-0370-28,NDC,outpatient,6,GR,250.85,175.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00310-7370-20,NDC,outpatient,10.2,GR,1011.48,708.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIFLUOPERAZINE HCL 1 MG ORAL TABS,RX-8161,CDM,S5000,HCPCS,259,RC,00781-8028-01,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIFLUOPERAZINE HCL 5 MG ORAL TABS,RX-8164,CDM,S5000,HCPCS,259,RC,00781-8034-01,NDC,outpatient,1,UN,4.68,3.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,00591-5335-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,69452-0241-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TRIHEXYPHENIDYL HCL 5 MG ORAL TABS,RX-8167,CDM,S5000,HCPCS,259,RC,70954-0211-10,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,68180-0407-03,NDC,outpatient,6.25,ML,50.07,35.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,99999-0002-91,NDC,outpatient,6.25,ML,120.07,84.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0070-30,NDC,outpatient,37.5,GR,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0627-63,NDC,outpatient,31,GR,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0626-53,NDC,outpatient,31,GR,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-15,NDC,outpatient,37.5,GR,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-30,NDC,outpatient,37.5,GR,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,50190-0141-23,NDC,outpatient,4,ML,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0207-60,NDC,outpatient,4,ML,3.01,2.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0307-60,NDC,outpatient,4,ML,1.2,0.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THROMBI-GEL 40 EX PADS,RX-82259,CDM,S5000,HCPCS,259,RC,60793-0908-04,NDC,outpatient,1,UN,254.02,177.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TROPICAMIDE 1 % OP SOLN,RX-8250,CDM,S5000,HCPCS,259,RC,70069-0121-01,NDC,outpatient,15,ML,25.3,17.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-15,NDC,outpatient,1,UN,93.94,65.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-61,NDC,outpatient,1,UN,93.94,65.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-03,NDC,outpatient,1,UN,24.46,17.122,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-11,NDC,outpatient,1,UN,24.46,17.122,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-21,NDC,outpatient,0.1,ML,35.98,25.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-78,NDC,outpatient,0.1,ML,35.98,25.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
UNNA-FLEX ELASTIC UNNA BOOT EX MISC,RX-8371,CDM,S5000,HCPCS,250,RC,68455-0107-63,NDC,outpatient,1,UN,44.16,30.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00832-0310-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00591-4012-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,69452-0150-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT,RX-849,CDM,S5000,HCPCS,259,RC,24208-0785-55,NDC,outpatient,3.5,GR,70.76,49.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-02,NDC,outpatient,2,ML,15.45,10.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-04,NDC,outpatient,2,ML,15.45,10.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,70710-1643-07,NDC,outpatient,2,ML,44.5,31.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-01,NDC,outpatient,2,ML,15.45,10.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL 120 MG ORAL TABS,RX-8528,CDM,S5000,HCPCS,259,RC,23155-0486-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL 40 MG ORAL TABS,RX-8529,CDM,S5000,HCPCS,259,RC,23155-0059-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VERAPAMIL HCL 80 MG ORAL TABS,RX-8530,CDM,S5000,HCPCS,259,RC,23155-0026-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,49348-0029-72,NDC,outpatient,30,GR,11.49,8.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,70677-0013-01,NDC,outpatient,28.4,GR,10.49,7.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,S5000,HCPCS,259,RC,00501-3798-05,NDC,outpatient,14.2,GR,20.67,14.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,S5000,HCPCS,259,RC,24208-0555-55,NDC,outpatient,3.5,GR,22.88,16.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00904-6475-61,NDC,outpatient,1,UN,1.6,1.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00527-1330-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,63739-0479-10,NDC,outpatient,1,UN,1.74,1.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN E 100 UNITS ORAL CAPS,RX-8698,CDM,S5000,HCPCS,259,RC,80681-0134-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,00536-1352-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-05,NDC,outpatient,5,GR,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-14,NDC,outpatient,5,GR,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-11,NDC,outpatient,1,UN,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-01,NDC,outpatient,1,UN,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-01,NDC,outpatient,1,UN,1.29,0.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-11,NDC,outpatient,1,UN,1.29,0.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0705-05,NDC,outpatient,1,UN,217.65,152.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0205-05,NDC,outpatient,1,UN,228.51,159.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,S5000,HCPCS,259,RC,35181-7303-32,NDC,outpatient,25,GR,146.52,102.564,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,82182-0455-05,NDC,outpatient,5,ML,356.54,249.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,00023-9211-05,NDC,outpatient,5,ML,838.92,587.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZEPAM 2.5 MG RE GEL,RX-87865,CDM,S5000,HCPCS,259,RC,68682-0650-20,NDC,outpatient,1,UN,430.63,301.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZEPAM 10 MG RE GEL,RX-87867,CDM,S5000,HCPCS,259,RC,68682-0652-20,NDC,outpatient,1,UN,622.96,436.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DIAZEPAM 20 MG RE GEL,RX-87869,CDM,S5000,HCPCS,259,RC,68682-0655-20,NDC,outpatient,1,UN,601.24,420.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-93,NDC,outpatient,2,ML,38.15,26.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-01,NDC,outpatient,2,ML,18.21,12.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-60,NDC,outpatient,2,ML,18.21,12.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-44,NDC,outpatient,2,ML,11.64,8.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-60,NDC,outpatient,2,ML,11.64,8.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-06,NDC,outpatient,2,ML,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-19,NDC,outpatient,2,ML,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-32,NDC,outpatient,2,ML,38.15,26.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,49502-0605-61,NDC,outpatient,2,ML,20.29,14.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RALTEGRAVIR POTASSIUM 400 MG ORAL TABS,RX-88608,CDM,S5000,HCPCS,259,RC,00006-0227-61,NDC,outpatient,1,UN,143.66,100.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-01,NDC,outpatient,10,ML,63.68,44.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-11,NDC,outpatient,10,ML,63.68,44.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,00004-0802-85,NDC,outpatient,1,UN,57.3,40.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,31722-0630-31,NDC,outpatient,1,UN,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OSELTAMIVIR PHOSPHATE 45 MG ORAL CAPS,RX-88705,CDM,S5000,HCPCS,259,RC,00004-0801-85,NDC,outpatient,1,UN,57.3,40.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,00536-1316-98,NDC,outpatient,454,GR,22.23,15.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,75834-0170-01,NDC,outpatient,28.4,GR,13.53,9.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-01,NDC,outpatient,10,ML,75.92,53.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-25,NDC,outpatient,10,ML,75.92,53.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-01,NDC,outpatient,5,ML,189.8,132.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-25,NDC,outpatient,5,ML,189.8,132.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,00904-6707-82,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-64,NDC,outpatient,1,UN,6.38,4.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-59,NDC,outpatient,1,UN,6.38,4.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
NEBIVOLOL HCL 5 MG ORAL TABS,RX-89284,CDM,S5000,HCPCS,259,RC,00904-7189-04,NDC,outpatient,1,UN,7.99,5.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-07,NDC,outpatient,1,UN,32.67,22.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-10,NDC,outpatient,1,UN,22.14,15.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-15,NDC,outpatient,1,UN,5.16,3.612,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-11,NDC,outpatient,1,UN,5.16,3.612,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,30103-0040-00,NDC,outpatient,60,GR,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,57074-0001-86,NDC,outpatient,60,GR,9.35,6.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-00,NDC,outpatient,5,ML,4.72,3.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-61,NDC,outpatient,5,ML,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-05,NDC,outpatient,5,ML,4.72,3.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-62,NDC,outpatient,5,ML,2.76,1.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-59,NDC,outpatient,5,ML,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,99999-0004-23,NDC,outpatient,5,ML,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,59676-0570-01,NDC,outpatient,1,UN,53.89,37.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,60219-1721-07,NDC,outpatient,1,UN,36.43,25.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-23,NDC,outpatient,1,UN,1.51,1.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-62,NDC,outpatient,1,UN,1.51,1.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,S5000,HCPCS,250,RC,00338-0322-01,NDC,outpatient,1,UN,281.38,196.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00904-6938-06,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,10702-0253-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-11,NDC,outpatient,1,UN,4.66,3.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00527-1695-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-65,NDC,outpatient,1,UN,4.66,3.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACETIC ACID 0.25 % IR SOLN,RX-8963,CDM,S5000,HCPCS,250,RC,00338-0656-04,NDC,outpatient,1000,ML,13.35,9.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,45802-0044-75,NDC,outpatient,5,GR,210.13,147.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,00187-0994-45,NDC,outpatient,5,GR,822.36,575.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,60505-0042-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,00904-5789-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,00472-0082-16,NDC,outpatient,473,ML,1582.85,1107.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,99999-0004-02,NDC,outpatient,5,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,31722-0681-47,NDC,outpatient,473,ML,244.17,170.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-01,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-11,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-62,NDC,outpatient,30,ML,11.09,7.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-01,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,57896-0629-12,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00121-1761-30,NDC,outpatient,30,ML,7.21,5.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-73,NDC,outpatient,30,ML,11.09,7.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-30,NDC,outpatient,30,ML,1.7,1.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,99999-0002-58,NDC,outpatient,30,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMINOCAPROIC ACID 500 MG ORAL TABS,RX-9063,CDM,S5000,HCPCS,259,RC,69680-0115-30,NDC,outpatient,1,UN,26.56,18.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00904-6993-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,63739-0051-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMLODIPINE BESYLATE 2.5 MG ORAL TABS,RX-9070,CDM,S5000,HCPCS,259,RC,00904-6369-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,00904-6370-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,68382-0122-16,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,42806-0341-01,NDC,outpatient,1,UN,1.52,1.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,64850-0502-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00591-3659-30,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00008-1211-14,NDC,outpatient,1,UN,5.76,4.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,51991-0311-90,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ROPINIROLE HCL ER 2 MG ORAL TB24,RX-92015,CDM,S5000,HCPCS,259,RC,55111-0659-30,NDC,outpatient,1,UN,2.69,1.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-15,NDC,outpatient,1,UN,2.09,1.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-11,NDC,outpatient,1,UN,2.09,1.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,S5000,HCPCS,259,RC,61314-0245-01,NDC,outpatient,5,ML,147.74,103.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10135-0623-01,NDC,outpatient,1,UN,2.28,1.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10702-0013-01,NDC,outpatient,1,UN,1.58,1.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
MOUTH KOTE MT SOLN,RX-92764,CDM,S5000,HCPCS,259,RC,50930-0098-02,NDC,outpatient,59,ML,21.53,15.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BROMOCRIPTINE MESYLATE 2.5 MG ORAL TABS,RX-9297,CDM,S5000,HCPCS,259,RC,00574-0106-03,NDC,outpatient,1,UN,3.28,2.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-15,NDC,outpatient,1,UN,5.55,3.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,42799-0119-01,NDC,outpatient,1,UN,1.43,1.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-11,NDC,outpatient,1,UN,5.55,3.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-05,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-15,NDC,outpatient,1,UN,3.09,2.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-01,NDC,outpatient,1,UN,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,69238-1490-01,NDC,outpatient,1,UN,1.61,1.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-11,NDC,outpatient,1,UN,3.09,2.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-11,NDC,outpatient,1,UN,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-57,NDC,outpatient,50,ML,49.4,34.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-01,NDC,outpatient,50,ML,49.4,34.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL 100 MG ORAL TABS,RX-9321,CDM,S5000,HCPCS,259,RC,00904-6636-61,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-15,NDC,outpatient,1,UN,2.99,2.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-11,NDC,outpatient,1,UN,2.99,2.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-11,NDC,outpatient,1,UN,3.85,2.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-01,NDC,outpatient,1,UN,3.85,2.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00093-0053-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00904-7122-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,69452-0207-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,23155-0662-01,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-32,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,66553-0004-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,00904-6412-92,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-33,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SORBITOL 70 % SOLN,RX-93927,CDM,S5000,HCPCS,259,RC,46287-0500-30,NDC,outpatient,30,ML,9.48,6.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-30,NDC,outpatient,3,ML,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-60,NDC,outpatient,3,ML,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-03,NDC,outpatient,3,ML,1.13,0.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,76204-0600-01,NDC,outpatient,3,ML,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-01,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-48,NDC,outpatient,3,ML,1.42,0.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-31,NDC,outpatient,3,ML,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-93,NDC,outpatient,3,ML,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-49,NDC,outpatient,3,ML,1.42,0.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAPTOPRIL 12.5 MG ORAL TABS,RX-9401,CDM,S5000,HCPCS,259,RC,00904-7105-61,NDC,outpatient,1,UN,6.29,4.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CAPTOPRIL 25 MG ORAL TABS,RX-9402,CDM,S5000,HCPCS,259,RC,00904-7106-61,NDC,outpatient,1,UN,5.2,3.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBIDOPA-LEVODOPA 10-100 MG ORAL TABS,RX-9406,CDM,S5000,HCPCS,259,RC,00093-9701-01,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,00093-9702-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-05,NDC,outpatient,1,ML,319.49,223.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-08,NDC,outpatient,1,ML,319.49,223.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,S5000,HCPCS,259,RC,00904-6255-49,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,60258-0162-01,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,63044-0622-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFACLOR 250 MG ORAL CAPS,RX-9430,CDM,S5000,HCPCS,259,RC,61442-0171-30,NDC,outpatient,1,UN,8.1,5.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,16714-0388-01,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,65862-0085-50,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-01,NDC,outpatient,1,UN,2.36,1.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-08,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,00781-5439-20,NDC,outpatient,1,UN,12.33,8.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,65862-0096-20,NDC,outpatient,1,UN,14.53,10.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,65862-0699-60,NDC,outpatient,1,UN,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,16714-0400-02,NDC,outpatient,1,UN,3.64,2.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,67877-0215-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-15,NDC,outpatient,1,UN,1.49,1.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-01,NDC,outpatient,1,UN,1.3,0.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-11,NDC,outpatient,1,UN,1.49,1.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-11,NDC,outpatient,1,UN,1.3,0.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,67877-0220-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-19,NDC,outpatient,15,ML,6.15,4.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-15,NDC,outpatient,15,ML,6.55,4.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,1,ML,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,5.99,4.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,54838-0011-50,NDC,outpatient,50,ML,14.02,9.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,99999-0003-94,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,61314-0656-05,NDC,outpatient,5,ML,15.4,10.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,69315-0308-05,NDC,outpatient,5,ML,62.3,43.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,00527-1931-06,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,65862-0225-60,NDC,outpatient,1,UN,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,59762-3743-01,NDC,outpatient,30,GR,208.26,145.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,00168-0202-30,NDC,outpatient,30,GR,207.33,145.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,69238-1532-05,NDC,outpatient,15,GR,19.83,13.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,51672-1258-02,NDC,outpatient,30,GR,31.11,21.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,21922-0017-05,NDC,outpatient,30,GR,42.19,29.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,51672-1259-02,NDC,outpatient,30,GR,43.53,30.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-25,NDC,outpatient,1,UN,36.81,25.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-95,NDC,outpatient,1,UN,36.81,25.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-11,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,43547-0407-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,16729-0137-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-11,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00054-4146-22,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00574-0107-70,NDC,outpatient,1,UN,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-01,NDC,outpatient,1,UN,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-01,NDC,outpatient,1,UN,4.21,2.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-11,NDC,outpatient,1,UN,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-20,NDC,outpatient,1,UN,4.21,2.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-01,NDC,outpatient,1,UN,2.14,1.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-20,NDC,outpatient,1,UN,2.14,1.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,S5000,HCPCS,259,RC,50484-0010-30,NDC,outpatient,30,GR,1218.46,852.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,S5000,HCPCS,259,RC,61314-0237-10,NDC,outpatient,10,ML,27.77,19.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-60,NDC,outpatient,1,UN,53.28,37.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-35,NDC,outpatient,1,UN,48.43,33.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,68462-0678-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,00131-2478-60,NDC,outpatient,1,UN,83.29,58.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,51991-0349-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-11,NDC,outpatient,1,UN,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,31722-0813-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-57,NDC,outpatient,1,UN,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,S5000,HCPCS,259,RC,00065-0397-02,NDC,outpatient,2,ML,180.67,126.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,S5000,HCPCS,259,RC,00065-0359-02,NDC,outpatient,2,ML,144.23,100.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-15,NDC,outpatient,1,UN,74.28,51.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-61,NDC,outpatient,1,UN,74.28,51.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,60505-0134-00,NDC,outpatient,1,UN,46.97,32.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-61,NDC,outpatient,1,UN,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-95,NDC,outpatient,1,UN,18.44,12.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-15,NDC,outpatient,1,UN,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-25,NDC,outpatient,1,UN,18.44,12.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,S5000,HCPCS,250,RC,42023-0123-06,NDC,outpatient,1,UN,288.51,201.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00904-7211-04,NDC,outpatient,1,UN,4.53,3.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00115-4411-01,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,55150-0173-01,NDC,outpatient,0.5,ML,17.69,12.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,63323-0273-01,NDC,outpatient,0.5,ML,24.66,17.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,99999-0002-38,NDC,outpatient,10,ML,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,60432-0608-16,NDC,outpatient,10,ML,3.48,2.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-00,NDC,outpatient,10,ML,7.53,5.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-10,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-04,NDC,outpatient,118,ML,17.33,12.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00904-7135-72,NDC,outpatient,10,ML,6.5,4.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-34,NDC,outpatient,118,ML,8.93,6.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-10,NDC,outpatient,10,ML,1.7,1.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-10,NDC,outpatient,10,ML,7.53,5.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,99999-0001-87,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
TOLVAPTAN 15 MG ORAL TABS,RX-97893,CDM,S5000,HCPCS,259,RC,59148-0020-50,NDC,outpatient,1,UN,1428.57,999.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS ORAL CPEP,RX-98034,CDM,S5000,HCPCS,259,RC,00032-0046-70,NDC,outpatient,1,UN,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-1224-01,NDC,outpatient,1,UN,33.86,23.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-2636-01,NDC,outpatient,1,UN,33.86,23.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN,RX-9809,CDM,S5000,HCPCS,250,RC,00264-7622-00,NDC,outpatient,1000,ML,51.6,36.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-9812,CDM,S5000,HCPCS,250,RC,00338-0077-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE-SODIUM CHLORIDE 5-0.33 % IV SOLN,RX-9813,CDM,S5000,HCPCS,250,RC,00264-7614-10,NDC,outpatient,500,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DRONEDARONE HCL 400 MG ORAL TABS,RX-98329,CDM,S5000,HCPCS,259,RC,00024-4142-60,NDC,outpatient,1,UN,53.6,37.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRASUGREL HCL 5 MG ORAL TABS,RX-98372,CDM,S5000,HCPCS,259,RC,60505-4642-03,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,1,UN,4.12,2.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,1,UN,1,0.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,1,UN,2.9,2.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZOIN COMPOUND EX TINC,RX-987,CDM,S5000,HCPCS,259,RC,00395-0243-92,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DINOPROSTONE 0.5 MG/3GM VA GEL,RX-9874,CDM,S5000,HCPCS,259,RC,00009-3359-01,NDC,outpatient,3,GR,1932.45,1352.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,00904-7153-61,NDC,outpatient,1,UN,1.32,0.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,64380-0712-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,69452-0143-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,42806-0714-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-25,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,00904-5522-61,NDC,outpatient,1,UN,2.36,1.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-95,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,60505-0095-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,00904-5524-61,NDC,outpatient,1,UN,2.28,1.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,16729-0213-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,99999-0002-89,NDC,outpatient,20,ML,27.06,18.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,68180-0657-01,NDC,outpatient,20,ML,27.06,18.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,S5000,HCPCS,259,RC,51672-1303-01,NDC,outpatient,15,GR,32.65,22.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,23155-0772-01,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,43547-0547-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENALAPRIL MALEATE 2.5 MG ORAL TABS,RX-9925,CDM,S5000,HCPCS,259,RC,16714-0442-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-01,NDC,outpatient,2,ML,34.39,24.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-10,NDC,outpatient,2,ML,34.39,24.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,99999-0002-24,NDC,outpatient,0.6,ML,13.98,9.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,42799-0217-01,NDC,outpatient,0.6,ML,13.98,9.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GLYCERIN (LAXATIVE) 1 G RE SUPP,RX-99417,CDM,S5000,HCPCS,259,RC,58980-0409-12,NDC,outpatient,1,UN,2.17,1.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0146-19,NDC,outpatient,1,UN,133.73,93.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0162-88,NDC,outpatient,1,UN,133.64,93.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ESTROGENS CONJUGATED 0.3 MG ORAL TABS,RX-9973,CDM,S5000,HCPCS,259,RC,00046-1100-81,NDC,outpatient,1,UN,28.4,19.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,42023-0157-01,NDC,outpatient,1,UN,1563.3,1094.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,67457-0297-50,NDC,outpatient,1,UN,2098.98,1469.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-01,NDC,outpatient,1,UN,1.82,1.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-11,NDC,outpatient,1,UN,1.82,1.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETHACRYNIC ACID 25 MG ORAL TABS,RX-9980,CDM,S5000,HCPCS,259,RC,69238-1126-01,NDC,outpatient,1,UN,8.7,6.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETHAMBUTOL HCL 400 MG ORAL TABS,RX-9983,CDM,S5000,HCPCS,259,RC,68850-0012-02,NDC,outpatient,1,UN,3.21,2.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,60505-3927-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,24979-0533-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
GUANFACINE HCL ER 2 MG ORAL TB24,RX-99836,CDM,S5000,HCPCS,259,RC,62332-0746-31,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,23155-0532-01,NDC,outpatient,1,UN,5.34,3.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,64380-0878-06,NDC,outpatient,1,UN,1.63,1.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-01,NDC,outpatient,1,UN,1.62,1.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-11,NDC,outpatient,1,UN,1.62,1.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,60505-0039-01,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,62559-0250-01,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
ETODOLAC 300 MG ORAL CAPS,RX-9998,CDM,S5000,HCPCS,259,RC,62559-0251-01,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures
HC Crisis Intervention Mental Health Services- per Diem,PX-90000001,CDM,S9485,HCPCS,900,RC,,,outpatient,,,1627,1138.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.9049,365.2615,1249.536,percent of total billed charges,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,outpatient,,,10370,7259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2682.719,399.86,9291.52,percent of total billed charges,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,outpatient,,,7029,4920.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1818.4023,399.86,9291.52,percent of total billed charges,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.690606,129.686915,921.62304,percent of total billed charges,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.443229,129.686915,921.62304,percent of total billed charges,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.443229,129.686915,921.62304,percent of total billed charges,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,310.447761,129.686915,921.62304,percent of total billed charges,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,310.447761,129.686915,921.62304,percent of total billed charges,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.690606,129.686915,921.62304,percent of total billed charges,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.690606,129.686915,921.62304,percent of total billed charges,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,541.64019,399.86,2223.8905,percent of total billed charges,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3992.7552,other,Non-Reimbursable Procedures
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3992.7552,other,Non-Reimbursable Procedures
Bilateral procedure,,,,,,,,,,,,,,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,CIGNA [1000112],CIGNA [100011201],,,,,,525.9295,1261.6,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,CIGNA [1000112],CIGNA [100011201],,,,,,808.0705,1938.4,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,CIGNA [1000112],CIGNA [100011201],,,,,,731.3655,1754.4,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,CIGNA [1000112],CIGNA [100011201],,,,,,1108.2205,2658.4,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,CIGNA [1000112],CIGNA [100011201],,,,,,594.6305,2483,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,CIGNA [1000112],CIGNA [100011201],,,,,,444.5555,1066.4,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,CIGNA [1000112],CIGNA [100011201],,,,,,398.5325,956,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,CIGNA [1000112],CIGNA [100011201],,,,,,1337.0015,3207.2,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,CIGNA [1000112],CIGNA [100011201],,,,,,1215.941,2916.8,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,CIGNA [1000112],CIGNA [100011201],,,,,,672.0025,1612,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,CIGNA [1000112],CIGNA [100011201],,,,,,1604.135,3848,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,CIGNA [1000112],CIGNA [100011201],,,,,,20.205,72,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,,,,26.491,94.4,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,CIGNA [1000112],CIGNA [100011201],,,,,,25.3685,90.4,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,CIGNA [1000112],CIGNA [100011201],,,,,,17.96,64,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,CIGNA [1000112],CIGNA [100011201],,,,,,17.7355,63.2,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,CIGNA [1000112],CIGNA [100011201],,,,,,59.9415,213.6,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,CIGNA [1000112],CIGNA [100011201],,,,,,20.205,72,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,CIGNA [1000112],CIGNA [100011201],,,,,,63.309,225.6,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,CIGNA [1000112],CIGNA [100011201],,,,,,60.166,214.4,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,CIGNA [1000112],CIGNA [100011201],,,,,,63.5335,226.4,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,CIGNA [1000112],CIGNA [100011201],,,,,,63.9825,228,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,,,,,64.4315,229.6,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,CIGNA [1000112],CIGNA [100011201],,,,,,68.9215,245.6,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,CIGNA [1000112],CIGNA [100011201],,,,,,94.9635,338.4,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,CIGNA [1000112],CIGNA [100011201],,,,,,98.331,350.4,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,CIGNA [1000112],CIGNA [100011201],,,,,,118.7605,423.2,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,CIGNA [1000112],CIGNA [100011201],,,,,,118.7605,423.2,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,CIGNA [1000112],CIGNA [100011201],,,,,,183.192,652.8,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,CIGNA [1000112],CIGNA [100011201],,,,,,871.958,3107.2,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,CIGNA [1000112],CIGNA [100011201],,,,,,1098.0295,3912.8,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,CIGNA [1000112],CIGNA [100011201],,,,,,1176.829,4193.6,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,CIGNA [1000112],CIGNA [100011201],,,,,,1227.117,4372.8,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,CIGNA [1000112],CIGNA [100011201],,,,,,149.7415,533.6,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,CIGNA [1000112],CIGNA [100011201],,,,,,79.2485,282.4,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,CIGNA [1000112],CIGNA [100011201],,,,,,73.4115,261.6,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,CIGNA [1000112],CIGNA [100011201],,,,,,87.555,312,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,CIGNA [1000112],CIGNA [100011201],,,,,,158.7215,565.6,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,CIGNA [1000112],CIGNA [100011201],,,,,,32.328,122.0544,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,,,,58.819,222.0712,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,CIGNA [1000112],CIGNA [100011201],,,,,,61.064,230.5472,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,CIGNA [1000112],CIGNA [100011201],,,,,,68.697,259.3656,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,CIGNA [1000112],CIGNA [100011201],,,,,,84.6365,319.5452,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,CIGNA [1000112],CIGNA [100011201],,,,,,105.7395,399.2196,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,CIGNA [1000112],CIGNA [100011201],,,,,,110.005,415.324,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,CIGNA [1000112],CIGNA [100011201],,,,,,210.8055,795.8964,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,CIGNA [1000112],CIGNA [100011201],,,,,,19.756,74.5888,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,CIGNA [1000112],CIGNA [100011201],,,,,,21.3275,80.522,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,CIGNA [1000112],CIGNA [100011201],,,,,,24.246,91.5408,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,CIGNA [1000112],CIGNA [100011201],,,,,,28.736,108.4928,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,CIGNA [1000112],CIGNA [100011201],,,,,,43.3285,163.5868,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,CIGNA [1000112],CIGNA [100011201],,,,,,43.7775,165.282,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,CIGNA [1000112],CIGNA [100011201],,,,,,50.5125,190.71,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,,,,,80.1465,302.5932,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,,,,,80.1465,302.5932,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,,,,,80.1465,302.5932,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,CIGNA [1000112],CIGNA [100011201],,,,,,83.963,317.0024,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,CIGNA [1000112],CIGNA [100011201],,,,,,88.902,335.6496,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,CIGNA [1000112],CIGNA [100011201],,,,,,90.249,340.7352,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,CIGNA [1000112],CIGNA [100011201],,,,,,91.8205,346.6684,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,CIGNA [1000112],CIGNA [100011201],,,,,,93.841,354.2968,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,CIGNA [1000112],CIGNA [100011201],,,,,,93.6165,353.4492,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,CIGNA [1000112],CIGNA [100011201],,,,,,100.127,378.0296,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,CIGNA [1000112],CIGNA [100011201],,,,,,101.2495,382.2676,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,,,,,104.617,394.9816,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,,,,,104.617,394.9816,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,CIGNA [1000112],CIGNA [100011201],,,,,,105.515,398.372,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,CIGNA [1000112],CIGNA [100011201],,,,,,109.556,413.6288,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,CIGNA [1000112],CIGNA [100011201],,,,,,115.842,437.3616,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,CIGNA [1000112],CIGNA [100011201],,,,,,116.5155,439.9044,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,CIGNA [1000112],CIGNA [100011201],,,,,,117.4135,443.2948,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,CIGNA [1000112],CIGNA [100011201],,,,,,121.4545,458.5516,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,CIGNA [1000112],CIGNA [100011201],,,,,,121.4545,458.5516,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,CIGNA [1000112],CIGNA [100011201],,,,,,124.822,471.2656,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,CIGNA [1000112],CIGNA [100011201],,,,,,151.313,571.2824,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,CIGNA [1000112],CIGNA [100011201],,,,,,155.803,588.2344,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,CIGNA [1000112],CIGNA [100011201],,,,,,155.803,588.2344,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,CIGNA [1000112],CIGNA [100011201],,,,,,155.803,588.2344,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,CIGNA [1000112],CIGNA [100011201],,,,,,157.8235,595.8628,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,CIGNA [1000112],CIGNA [100011201],,,,,,161.4155,609.4244,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,CIGNA [1000112],CIGNA [100011201],,,,,,162.089,611.9672,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,CIGNA [1000112],CIGNA [100011201],,,,,,164.1095,619.5956,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,CIGNA [1000112],CIGNA [100011201],,,,,,171.7425,648.414,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,CIGNA [1000112],CIGNA [100011201],,,,,,174.212,657.7376,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,CIGNA [1000112],CIGNA [100011201],,,,,,174.212,657.7376,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,,,,189.7025,716.222,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,,,,189.7025,716.222,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,,,,189.7025,716.222,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,CIGNA [1000112],CIGNA [100011201],,,,,,200.9275,758.602,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,CIGNA [1000112],CIGNA [100011201],,,,,,200.9275,758.602,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,CIGNA [1000112],CIGNA [100011201],,,,,,185.6615,700.9652,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,CIGNA [1000112],CIGNA [100011201],,,,,,210.8055,795.8964,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,CIGNA [1000112],CIGNA [100011201],,,,,,219.7855,829.8004,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,CIGNA [1000112],CIGNA [100011201],,,,,,354.9345,1340.0556,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,CIGNA [1000112],CIGNA [100011201],,,,,,354.9345,1340.0556,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,CIGNA [1000112],CIGNA [100011201],,,,,,255.032,962.8736,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,CIGNA [1000112],CIGNA [100011201],,,,,,284.8905,1075.6044,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,CIGNA [1000112],CIGNA [100011201],,,,,,296.1155,1117.9844,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,CIGNA [1000112],CIGNA [100011201],,,,,,314.0755,1185.7924,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,CIGNA [1000112],CIGNA [100011201],,,,,,316.096,1193.4208,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,CIGNA [1000112],CIGNA [100011201],,,,,,455.0615,1718.0852,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,CIGNA [1000112],CIGNA [100011201],,,,,,498.1655,1880.8244,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,CIGNA [1000112],CIGNA [100011201],,,,,,584.149,2205.4552,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,CIGNA [1000112],CIGNA [100011201],,,,,,660.7035,2494.4868,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,CIGNA [1000112],CIGNA [100011201],,,,,,1249.3425,4716.894,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,CIGNA [1000112],CIGNA [100011201],,,,,,1237.444,4671.9712,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,CIGNA [1000112],CIGNA [100011201],,,,,,924.94,3492.112,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,CIGNA [1000112],CIGNA [100011201],,,,,,1237.444,4671.9712,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,CIGNA [1000112],CIGNA [100011201],,,,,,302.8505,1143.4124,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,CIGNA [1000112],CIGNA [100011201],,,,,,8.7555,33.0564,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,CIGNA [1000112],CIGNA [100011201],,,,,,277.931,1049.3288,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,CIGNA [1000112],CIGNA [100011201],,,,,,249.8685,943.3788,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,CIGNA [1000112],CIGNA [100011201],,,,,,423.6315,1599.4212,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,CIGNA [1000112],CIGNA [100011201],,,,,,246.2765,929.8172,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,CIGNA [1000112],CIGNA [100011201],,,,,,337.648,1274.7904,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,CIGNA [1000112],CIGNA [100011201],,,,,,71.6155,270.3844,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,CIGNA [1000112],CIGNA [100011201],,,,,,103.719,391.5912,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,CIGNA [1000112],CIGNA [100011201],,,,,,241.7865,912.8652,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,CIGNA [1000112],CIGNA [100011201],,,,,,109.107,411.9336,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,CIGNA [1000112],CIGNA [100011201],,,,,,100.3515,378.8772,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,CIGNA [1000112],CIGNA [100011201],,,,,,299.034,1129.0032,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,CIGNA [1000112],CIGNA [100011201],,,,,,66.6765,251.7372,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,CIGNA [1000112],CIGNA [100011201],,,,,,120.5565,455.1612,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,CIGNA [1000112],CIGNA [100011201],,,,,,126.8425,478.894,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,CIGNA [1000112],CIGNA [100011201],,,,,,93.6165,353.4492,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,CIGNA [1000112],CIGNA [100011201],,,,,,92.494,349.2112,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,CIGNA [1000112],CIGNA [100011201],,,,,,155.1295,585.6916,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,CIGNA [1000112],CIGNA [100011201],,,,,,113.597,428.8856,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,CIGNA [1000112],CIGNA [100011201],,,,,,95.188,359.3824,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,CIGNA [1000112],CIGNA [100011201],,,,,,133.353,503.4744,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,CIGNA [1000112],CIGNA [100011201],,,,,,118.7605,448.3804,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,CIGNA [1000112],CIGNA [100011201],,,,,,203.397,767.9256,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,CIGNA [1000112],CIGNA [100011201],,,,,,145.476,549.2448,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,CIGNA [1000112],CIGNA [100011201],,,,,,222.255,839.124,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,CIGNA [1000112],CIGNA [100011201],,,,,,194.1925,733.174,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,CIGNA [1000112],CIGNA [100011201],,,,,,97.2085,367.0108,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,CIGNA [1000112],CIGNA [100011201],,,,,,88.453,333.9544,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,CIGNA [1000112],CIGNA [100011201],,,,,,136.047,513.6456,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,CIGNA [1000112],CIGNA [100011201],,,,,,157.15,593.32,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,CIGNA [1000112],CIGNA [100011201],,,,,,495.0225,1868.958,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,CIGNA [1000112],CIGNA [100011201],,,,,,299.932,1132.3936,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,CIGNA [1000112],CIGNA [100011201],,,,,,245.603,927.2744,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,CIGNA [1000112],CIGNA [100011201],,,,,,266.706,1006.9488,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,CIGNA [1000112],CIGNA [100011201],,,,,,259.073,978.1304,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,CIGNA [1000112],CIGNA [100011201],,,,,,259.073,978.1304,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,CIGNA [1000112],CIGNA [100011201],,,,,,176.2325,665.366,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,CIGNA [1000112],CIGNA [100011201],,,,,,174.8855,660.2804,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,CIGNA [1000112],CIGNA [100011201],,,,,,267.3795,1009.4916,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,CIGNA [1000112],CIGNA [100011201],,,,,,220.6835,833.1908,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,CIGNA [1000112],CIGNA [100011201],,,,,,102.5965,387.3532,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,CIGNA [1000112],CIGNA [100011201],,,,,,105.7395,399.2196,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,CIGNA [1000112],CIGNA [100011201],,,,,,104.3925,394.134,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,CIGNA [1000112],CIGNA [100011201],,,,,,184.7635,697.5748,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,CIGNA [1000112],CIGNA [100011201],,,,,,138.9655,524.6644,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,CIGNA [1000112],CIGNA [100011201],,,,,,178.4775,673.842,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,CIGNA [1000112],CIGNA [100011201],,,,,,162.089,611.9672,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,CIGNA [1000112],CIGNA [100011201],,,,,,55.0025,207.662,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,CIGNA [1000112],CIGNA [100011201],,,,,,214.173,808.6104,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,CIGNA [1000112],CIGNA [100011201],,,,,,259.073,978.1304,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,CIGNA [1000112],CIGNA [100011201],,,,,,111.5765,421.2572,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,CIGNA [1000112],CIGNA [100011201],,,,,,56.3495,212.7476,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,CIGNA [1000112],CIGNA [100011201],,,,,,91.596,345.8208,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,CIGNA [1000112],CIGNA [100011201],,,,,,100.3515,378.8772,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,CIGNA [1000112],CIGNA [100011201],,,,,,80.5955,304.2884,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,CIGNA [1000112],CIGNA [100011201],,,,,,70.044,264.4512,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,CIGNA [1000112],CIGNA [100011201],,,,,,70.044,264.4512,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,CIGNA [1000112],CIGNA [100011201],,,,,,139.639,527.2072,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,CIGNA [1000112],CIGNA [100011201],,,,,,123.924,467.8752,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,CIGNA [1000112],CIGNA [100011201],,,,,,274.1145,1034.9196,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,CIGNA [1000112],CIGNA [100011201],,,,,,846.814,3197.1472,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,CIGNA [1000112],CIGNA [100011201],,,,,,438.673,1656.2104,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,CIGNA [1000112],CIGNA [100011201],,,,,,854.447,3225.9656,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,CIGNA [1000112],CIGNA [100011201],,,,,,148.3945,560.2636,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,CIGNA [1000112],CIGNA [100011201],,,,,,127.965,483.132,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,CIGNA [1000112],CIGNA [100011201],,,,,,127.965,483.132,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,CIGNA [1000112],CIGNA [100011201],,,,,,759.9325,2869.126,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,CIGNA [1000112],CIGNA [100011201],,,,,,715.0325,2699.606,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,CIGNA [1000112],CIGNA [100011201],,,,,,85.31,322.088,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,CIGNA [1000112],CIGNA [100011201],,,,,,174.8855,660.2804,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,CIGNA [1000112],CIGNA [100011201],,,,,,74.085,279.708,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,CIGNA [1000112],CIGNA [100011201],,,,,,85.759,323.7832,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,CIGNA [1000112],CIGNA [100011201],,,,,,100.576,379.7248,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,CIGNA [1000112],CIGNA [100011201],,,,,,106.1885,400.9148,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,,,,,112.699,425.4952,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,,,,147.721,557.7208,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,CIGNA [1000112],CIGNA [100011201],,,,,,148.3945,560.2636,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,CIGNA [1000112],CIGNA [100011201],,,,,,157.8235,595.8628,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,CIGNA [1000112],CIGNA [100011201],,,,,,167.2525,631.462,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,CIGNA [1000112],CIGNA [100011201],,,,,,176.2325,665.366,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,CIGNA [1000112],CIGNA [100011201],,,,,,202.2745,763.6876,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,,,,205.4175,775.554,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,CIGNA [1000112],CIGNA [100011201],,,,,,250.7665,946.7692,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,CIGNA [1000112],CIGNA [100011201],,,,,,574.72,2169.856,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,CIGNA [1000112],CIGNA [100011201],,,,,,574.72,2169.856,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,,,,,667.663,2520.7624,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,CIGNA [1000112],CIGNA [100011201],,,,,,675.9695,2552.1236,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,CIGNA [1000112],CIGNA [100011201],,,,,,675.9695,2552.1236,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,CIGNA [1000112],CIGNA [100011201],,,,,,710.5425,2682.654,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,CIGNA [1000112],CIGNA [100011201],,,,,,767.341,2897.0968,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,CIGNA [1000112],CIGNA [100011201],,,,,,777.219,2934.3912,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,CIGNA [1000112],CIGNA [100011201],,,,,,1481.0265,5591.6172,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,,,,147.721,557.7208,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,,,,147.721,557.7208,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,CIGNA [1000112],CIGNA [100011201],,,,,,276.584,1044.2432,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,CIGNA [1000112],CIGNA [100011201],,,,,,392.875,1483.3,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,CIGNA [1000112],CIGNA [100011201],,,,,,882.9585,3333.6108,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,CIGNA [1000112],CIGNA [100011201],,,,,,923.593,3487.0264,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,CIGNA [1000112],CIGNA [100011201],,,,,,1001.4945,3781.1436,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,,,,,104.617,394.9816,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,,,,,667.663,2520.7624,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,,,,,667.663,2520.7624,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,,,,,667.663,2520.7624,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,CIGNA [1000112],CIGNA [100011201],,,,,,238.419,900.1512,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,CIGNA [1000112],CIGNA [100011201],,,,,,238.419,900.1512,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,CIGNA [1000112],CIGNA [100011201],,,,,,238.419,900.1512,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,CIGNA [1000112],CIGNA [100011201],,,,,,324.4025,1224.782,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,CIGNA [1000112],CIGNA [100011201],,,,,,100.576,379.7248,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,,,,77.9015,294.1172,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,CIGNA [1000112],CIGNA [100011201],,,,,,239.0925,902.694,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,CIGNA [1000112],CIGNA [100011201],,,,,,79.2485,299.2028,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,CIGNA [1000112],CIGNA [100011201],,,,,,317.2185,1197.6588,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,CIGNA [1000112],CIGNA [100011201],,,,,,289.605,1093.404,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,CIGNA [1000112],CIGNA [100011201],,,,,,289.605,1093.404,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,CIGNA [1000112],CIGNA [100011201],,,,,,479.3075,1809.626,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,CIGNA [1000112],CIGNA [100011201],,,,,,167.2525,631.462,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,,,,58.819,222.0712,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,,,,58.819,222.0712,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,CIGNA [1000112],CIGNA [100011201],,,,,,79.2485,299.2028,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,CIGNA [1000112],CIGNA [100011201],,,,,,288.707,1090.0136,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,CIGNA [1000112],CIGNA [100011201],,,,,,145.7005,550.0924,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,CIGNA [1000112],CIGNA [100011201],,,,,,170.171,642.4808,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,CIGNA [1000112],CIGNA [100011201],,,,,,238.6435,900.9988,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,CIGNA [1000112],CIGNA [100011201],,,,,,245.3785,926.4268,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,CIGNA [1000112],CIGNA [100011201],,,,,,273.2165,1031.5292,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,CIGNA [1000112],CIGNA [100011201],,,,,,304.1975,1148.498,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,CIGNA [1000112],CIGNA [100011201],,,,,,313.851,1184.9448,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,CIGNA [1000112],CIGNA [100011201],,,,,,330.913,1249.3624,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,CIGNA [1000112],CIGNA [100011201],,,,,,336.5255,1270.5524,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,CIGNA [1000112],CIGNA [100011201],,,,,,398.0385,1502.7948,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,CIGNA [1000112],CIGNA [100011201],,,,,,355.8325,1343.446,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,CIGNA [1000112],CIGNA [100011201],,,,,,367.282,1386.6736,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,CIGNA [1000112],CIGNA [100011201],,,,,,392.6505,1482.4524,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,CIGNA [1000112],CIGNA [100011201],,,,,,106.413,401.7624,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,CIGNA [1000112],CIGNA [100011201],,,,,,106.413,401.7624,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,CIGNA [1000112],CIGNA [100011201],,,,,,106.413,401.7624,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,CIGNA [1000112],CIGNA [100011201],,,,,,73.636,278.0128,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,CIGNA [1000112],CIGNA [100011201],,,,,,109.107,411.9336,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,CIGNA [1000112],CIGNA [100011201],,,,,,398.0385,1502.7948,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,CIGNA [1000112],CIGNA [100011201],,,,,,155.803,588.2344,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,CIGNA [1000112],CIGNA [100011201],,,,,,106.413,401.7624,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,CIGNA [1000112],CIGNA [100011201],,,,,,106.6375,402.61,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,CIGNA [1000112],CIGNA [100011201],,,,,,383.895,1449.396,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,CIGNA [1000112],CIGNA [100011201],,,,,,297.9115,1124.7652,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,CIGNA [1000112],CIGNA [100011201],,,,,,297.9115,1124.7652,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,CIGNA [1000112],CIGNA [100011201],,,,,,291.85,1101.88,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,CIGNA [1000112],CIGNA [100011201],,,,,,7.184,27.1232,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,CIGNA [1000112],CIGNA [100011201],,,,,,31.879,120.3592,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,CIGNA [1000112],CIGNA [100011201],,,,,,35.2465,133.0732,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,CIGNA [1000112],CIGNA [100011201],,,,,,34.124,128.8352,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,CIGNA [1000112],CIGNA [100011201],,,,,,46.696,176.3008,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,CIGNA [1000112],CIGNA [100011201],,,,,,13.47,50.856,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,CIGNA [1000112],CIGNA [100011201],,,,,,16.8375,63.57,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,CIGNA [1000112],CIGNA [100011201],,,,,,13.47,50.856,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,CIGNA [1000112],CIGNA [100011201],,,,,,16.8375,63.57,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,CIGNA [1000112],CIGNA [100011201],,,,,,22.2255,83.9124,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,CIGNA [1000112],CIGNA [100011201],,,,,,31.43,118.664,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,CIGNA [1000112],CIGNA [100011201],,,,,,30.981,116.9688,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,CIGNA [1000112],CIGNA [100011201],,,,,,35.6955,134.7684,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,CIGNA [1000112],CIGNA [100011201],,,,,,157.15,593.32,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,CIGNA [1000112],CIGNA [100011201],,,,,,190.825,720.46,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,CIGNA [1000112],CIGNA [100011201],,,,,,373.119,1408.7112,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,CIGNA [1000112],CIGNA [100011201],,,,,,213.275,805.22,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,CIGNA [1000112],CIGNA [100011201],,,,,,656.438,2478.3824,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,CIGNA [1000112],CIGNA [100011201],,,,,,269.4,1017.12,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,CIGNA [1000112],CIGNA [100011201],,,,,,956.819,3612.4712,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,CIGNA [1000112],CIGNA [100011201],,,,,,2057.767,7769.1016,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,CIGNA [1000112],CIGNA [100011201],,,,,,269.4,1017.12,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,CIGNA [1000112],CIGNA [100011201],,,,,,841.6505,3177.6524,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,CIGNA [1000112],CIGNA [100011201],,,,,,1202.422,4539.7456,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,CIGNA [1000112],CIGNA [100011201],,,,,,2164.4045,8171.7116,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,CIGNA [1000112],CIGNA [100011201],,,,,,5.6125,21.19,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,CIGNA [1000112],CIGNA [100011201],,,,,,4.939,18.6472,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,CIGNA [1000112],CIGNA [100011201],,,,,,5.1635,19.4948,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,CIGNA [1000112],CIGNA [100011201],,,,,,6.286,23.7328,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,CIGNA [1000112],CIGNA [100011201],,,,,,6.5105,24.5804,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,CIGNA [1000112],CIGNA [100011201],,,,,,7.4085,27.9708,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,CIGNA [1000112],CIGNA [100011201],,,,,,8.531,32.2088,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,CIGNA [1000112],CIGNA [100011201],,,,,,336.75,1271.4,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,CIGNA [1000112],CIGNA [100011201],,,,,,22.6745,6652,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,CIGNA [1000112],CIGNA [100011201],,,,,,127.7405,482.2844,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,CIGNA [1000112],CIGNA [100011201],,,,,,127.7405,482.2844,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,CIGNA [1000112],CIGNA [100011201],,,,,,6.5105,24.5804,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,CIGNA [1000112],CIGNA [100011201],,,,,,1.5715,163,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,CIGNA [1000112],CIGNA [100011201],,,,,,9.6535,163,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,CIGNA [1000112],CIGNA [100011201],,,,,,38.3895,163,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,CIGNA [1000112],CIGNA [100011201],,,,,,399.86,9291.52,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,CIGNA [1000112],CIGNA [100011201],,,,,,399.86,6297.984,,
Heart Transplant Or Implant Of Heart Assist System With McC,1,MS-DRG,,,,,,,inpatient,,,509415.58,356590.906,CIGNA [1000112],CIGNA [100011201],,,68,,346402.5944,7771.48,570763.9296,percent of total billed charges,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,495073.43,346551.401,CIGNA [1000112],CIGNA [100011201],,,68,,336649.9324,7771.48,434261.5728,percent of total billed charges,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,347238.19,243066.733,CIGNA [1000112],CIGNA [100011201],,,68,,236121.9692,7771.48,286312.0824,percent of total billed charges,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,111379.6,77965.72,CIGNA [1000112],CIGNA [100011201],,,68,,75738.128,7771.48,109336.4384,percent of total billed charges,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,80508.95,56356.265,CIGNA [1000112],CIGNA [100011201],,,68,,54746.086,7771.48,90620.608,percent of total billed charges,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,64638.3,45246.81,CIGNA [1000112],CIGNA [100011201],,,68,,43954.044,7771.48,123186.8824,percent of total billed charges,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,31748.36,22223.852,CIGNA [1000112],CIGNA [100011201],,,68,,21588.8848,7771.48,68016.116,percent of total billed charges,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,38853.43,27197.401,CIGNA [1000112],CIGNA [100011201],,,68,,26420.3324,7771.48,45091.4528,percent of total billed charges,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,36305.14,25413.598,CIGNA [1000112],CIGNA [100011201],,,68,,24687.4952,7771.48,32329.1856,percent of total billed charges,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,66447.77,46513.439,CIGNA [1000112],CIGNA [100011201],,,68,,45184.4836,7771.48,78796.564,percent of total billed charges,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,67076.27,46953.389,CIGNA [1000112],CIGNA [100011201],,,68,,45611.8636,7771.48,53661.016,percent of total billed charges,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,60360.78,42252.546,CIGNA [1000112],CIGNA [100011201],,,68,,41045.3304,7771.48,48288.624,percent of total billed charges,
Extracranial Procedures With McC,37,MS-DRG,,,,,,,inpatient,,,89958.63,62971.041,CIGNA [1000112],CIGNA [100011201],,,68,,61171.8684,7771.48,71966.904,percent of total billed charges,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,41578.78,29105.146,CIGNA [1000112],CIGNA [100011201],,,68,,28273.5704,7771.48,33263.024,percent of total billed charges,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,33795.18,23656.626,CIGNA [1000112],CIGNA [100011201],,,68,,22980.7224,7771.48,27036.144,percent of total billed charges,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,68215.86,47751.102,CIGNA [1000112],CIGNA [100011201],,,68,,46386.7848,7771.48,54572.688,percent of total billed charges,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,26930.4,18851.28,CIGNA [1000112],CIGNA [100011201],,,68,,18312.672,7771.48,30377.7624,percent of total billed charges,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,21358.75,14951.125,CIGNA [1000112],CIGNA [100011201],,,68,,14523.95,7123.143125,22105.9976,percent of total billed charges,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,44783.08,31348.156,CIGNA [1000112],CIGNA [100011201],,,68,,30452.4944,7771.48,50741.056,percent of total billed charges,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,47305.96,33114.172,CIGNA [1000112],CIGNA [100011201],,,68,,32168.0528,7771.48,37844.768,percent of total billed charges,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,15006.39,10504.473,CIGNA [1000112],CIGNA [100011201],,,68,,10204.3452,5004.631065,37401.2648,percent of total billed charges,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,24159.04,16911.328,CIGNA [1000112],CIGNA [100011201],,,68,,16428.1472,7771.48,24793.004,percent of total billed charges,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,28159.44,19711.608,CIGNA [1000112],CIGNA [100011201],,,68,,19148.4192,6624.72,22527.552,percent of total billed charges,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,89978.5,62984.95,CIGNA [1000112],CIGNA [100011201],,,68,,61185.38,7771.48,71982.8,percent of total billed charges,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,41764.16,29234.912,CIGNA [1000112],CIGNA [100011201],,,68,,28399.6288,7771.48,36086.1312,percent of total billed charges,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,42817.54,29972.278,CIGNA [1000112],CIGNA [100011201],,,68,,29115.9272,7771.48,34254.032,percent of total billed charges,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,29171.68,20420.176,CIGNA [1000112],CIGNA [100011201],,,68,,19836.7424,7771.48,40307.1224,percent of total billed charges,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20113.63,14079.541,CIGNA [1000112],CIGNA [100011201],,,68,,13677.2684,6707.895605,20608.488,percent of total billed charges,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,15729.11,11010.377,CIGNA [1000112],CIGNA [100011201],,,68,,10695.7948,5143.64,13947.7112,percent of total billed charges,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,46442.5,32509.75,CIGNA [1000112],CIGNA [100011201],,,68,,31580.9,7771.48,37154,percent of total billed charges,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,28051.55,19636.085,CIGNA [1000112],CIGNA [100011201],,,68,,19075.054,6429.37,22441.24,percent of total billed charges,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17263.03,12084.121,CIGNA [1000112],CIGNA [100011201],,,68,,11738.8604,5687.74,16215.2528,percent of total billed charges,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,34983.65,24488.555,CIGNA [1000112],CIGNA [100011201],,,68,,23788.882,7771.48,35233.0168,percent of total billed charges,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,19683.37,13778.359,CIGNA [1000112],CIGNA [100011201],,,68,,13384.6916,6564.403895,21354.2032,percent of total billed charges,
Nonspecific Cerebrovascular Disorders Without Cc/McC,72,MS-DRG,,,,,,,inpatient,,,12084.89,8459.423,CIGNA [1000112],CIGNA [100011201],,,68,,8217.7252,4030.310815,15200.0264,percent of total billed charges,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,16388.09,11471.663,CIGNA [1000112],CIGNA [100011201],,,68,,11143.9012,5465.428015,31318.012,percent of total billed charges,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,28055.14,19638.598,CIGNA [1000112],CIGNA [100011201],,,68,,19077.4952,7368.52,22444.112,percent of total billed charges,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,26116.94,18281.858,CIGNA [1000112],CIGNA [100011201],,,68,,17759.5192,7097.19,20893.552,percent of total billed charges,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,23235.5,16264.85,CIGNA [1000112],CIGNA [100011201],,,68,,15800.14,7749.03925,31332.1968,percent of total billed charges,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,15869.98,11108.986,CIGNA [1000112],CIGNA [100011201],,,68,,10791.5864,5292.63833,20219.4192,percent of total billed charges,
Hypertensive Encephalopathy Without Cc/McC,79,MS-DRG,,,,,,,inpatient,,,15211.5,10648.05,CIGNA [1000112],CIGNA [100011201],,,68,,10343.82,5073.03525,13510.0088,percent of total billed charges,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,53186.54,37230.578,CIGNA [1000112],CIGNA [100011201],,,68,,36166.8472,7771.48,42549.232,percent of total billed charges,
Nontraumatic Stupor And Coma Without McC,81,MS-DRG,,,,,,,inpatient,,,72271.24,50589.868,CIGNA [1000112],CIGNA [100011201],,,68,,49144.4432,5585.72,57816.992,percent of total billed charges,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,28572.47,20000.729,CIGNA [1000112],CIGNA [100011201],,,68,,19429.2796,7771.48,47014.5064,percent of total billed charges,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,30376.08,21263.256,CIGNA [1000112],CIGNA [100011201],,,68,,20655.7344,7771.48,28173.0392,percent of total billed charges,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,15324.04,10726.828,CIGNA [1000112],CIGNA [100011201],,,68,,10420.3472,5110.56734,19372.384,percent of total billed charges,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,40898.43,28628.901,CIGNA [1000112],CIGNA [100011201],,,68,,27810.9324,7771.48,45916.1976,percent of total billed charges,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,13317.55,9322.285,CIGNA [1000112],CIGNA [100011201],,,68,,9055.934,4441.402925,26578.2624,percent of total billed charges,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,24255.02,16978.514,CIGNA [1000112],CIGNA [100011201],,,68,,16493.4136,6241.25,19404.016,percent of total billed charges,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,42230.83,29561.581,CIGNA [1000112],CIGNA [100011201],,,68,,28716.9644,7771.48,36937.2192,percent of total billed charges,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,30155.68,21108.976,CIGNA [1000112],CIGNA [100011201],,,68,,20505.8624,7134.82,24124.544,percent of total billed charges,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,16152.97,11307.079,CIGNA [1000112],CIGNA [100011201],,,68,,10984.0196,5387.015495,15994.3752,percent of total billed charges,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,56481.63,39537.141,CIGNA [1000112],CIGNA [100011201],,,68,,38407.5084,7771.48,73931.1776,percent of total billed charges,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,49973.83,34981.681,CIGNA [1000112],CIGNA [100011201],,,68,,33982.2044,7771.48,72642.3872,percent of total billed charges,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,15617.77,10932.439,CIGNA [1000112],CIGNA [100011201],,,68,,10620.0836,5208.526295,43954.6424,percent of total billed charges,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC,99,MS-DRG,,,,,,,inpatient,,,27081.74,18957.218,CIGNA [1000112],CIGNA [100011201],,,68,,18415.5832,7771.48,28231.8048,percent of total billed charges,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,34012.87,23809.009,CIGNA [1000112],CIGNA [100011201],,,68,,23128.7516,7771.48,40228.0928,percent of total billed charges,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,18803.33,13162.331,CIGNA [1000112],CIGNA [100011201],,,68,,12786.2644,6270.910555,18675.3024,percent of total billed charges,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,27377.14,19163.998,CIGNA [1000112],CIGNA [100011201],,,68,,18616.4552,7771.48,23494.0816,percent of total billed charges,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,23893.76,16725.632,CIGNA [1000112],CIGNA [100011201],,,68,,16247.7568,5992.35,19115.008,percent of total billed charges,
Acute Major Eye Infections With Cc/McC,121,MS-DRG,,,,,,,inpatient,,,20815.14,14570.598,CIGNA [1000112],CIGNA [100011201],,,68,,14154.2952,6941.84919,23569.0584,percent of total billed charges,
Acute Major Eye Infections Without Cc/McC,122,MS-DRG,,,,,,,inpatient,,,8234.57,5764.199,CIGNA [1000112],CIGNA [100011201],,,68,,5599.5076,2746.229095,13745.0712,percent of total billed charges,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,28026.78,19618.746,CIGNA [1000112],CIGNA [100011201],,,68,,19058.2104,5537.24,22421.424,percent of total billed charges,
Other Disorders Of The Eye With McC Or Thrombolytic Agent,124,MS-DRG,,,,,,,inpatient,,,12298.33,8608.831,CIGNA [1000112],CIGNA [100011201],,,68,,8362.8644,4101.493055,26420.2032,percent of total billed charges,
Other Disorders Of The Eye Without McC,125,MS-DRG,,,,,,,inpatient,,,18740.93,13118.651,CIGNA [1000112],CIGNA [100011201],,,68,,12743.8324,6044.44,16731.9848,percent of total billed charges,
Mouth Procedures With Cc/McC,137,MS-DRG,,,,,,,inpatient,,,29533.69,20673.583,CIGNA [1000112],CIGNA [100011201],,,68,,20082.9092,7771.48,28339.204,percent of total billed charges,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,44941.05,31458.735,CIGNA [1000112],CIGNA [100011201],,,68,,30559.914,7771.48,66905.6488,percent of total billed charges,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,9316.44,6521.508,CIGNA [1000112],CIGNA [100011201],,,68,,6335.1792,3107.03274,35595.7424,percent of total billed charges,
Ear- Nose- Mouth And Throat Malignancy With McC,146,MS-DRG,,,,,,,inpatient,,,13156.92,9209.844,CIGNA [1000112],CIGNA [100011201],,,68,,8946.7056,4387.83282,46483.5896,percent of total billed charges,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,13619.01,9533.307,CIGNA [1000112],CIGNA [100011201],,,68,,9260.9268,4541.939835,15147.34,percent of total billed charges,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,14296.01,10007.207,CIGNA [1000112],CIGNA [100011201],,,68,,9721.2868,4767.719335,15360.112,percent of total billed charges,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,12866.36,9006.452,CIGNA [1000112],CIGNA [100011201],,,68,,8749.1248,4290.93106,22993.5608,percent of total billed charges,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,16420.88,11494.616,CIGNA [1000112],CIGNA [100011201],,,68,,11166.1984,5141.47,14421.8888,percent of total billed charges,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,12009,8406.3,CIGNA [1000112],CIGNA [100011201],,,68,,8166.12,4005.0015,32953.3168,percent of total billed charges,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,39912.51,27938.757,CIGNA [1000112],CIGNA [100011201],,,68,,27140.5068,6561.05,31930.008,percent of total billed charges,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,11067.63,7747.341,CIGNA [1000112],CIGNA [100011201],,,68,,7525.9884,3691.054605,13625.5136,percent of total billed charges,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,32953.66,23067.562,CIGNA [1000112],CIGNA [100011201],,,68,,22408.4888,7771.48,33180.2736,percent of total billed charges,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,27223.03,19056.121,CIGNA [1000112],CIGNA [100011201],,,68,,18511.6604,6432.99,21778.424,percent of total billed charges,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,2839.79,1987.853,CIGNA [1000112],CIGNA [100011201],,,68,,1931.0572,947.069965,13366.1344,percent of total billed charges,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,115551.53,80886.071,CIGNA [1000112],CIGNA [100011201],,,68,,78575.0404,7771.48,93394.7496,percent of total billed charges,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,85038.13,59526.691,CIGNA [1000112],CIGNA [100011201],,,68,,57825.9284,7771.48,68030.504,percent of total billed charges,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,69826.08,48878.256,CIGNA [1000112],CIGNA [100011201],,,68,,47481.7344,7771.48,55860.864,percent of total billed charges,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,55683.12,38978.184,CIGNA [1000112],CIGNA [100011201],,,68,,37864.5216,7771.48,78036.664,percent of total billed charges,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,45649.7,31954.79,CIGNA [1000112],CIGNA [100011201],,,68,,31041.796,7771.48,37024.3544,percent of total billed charges,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,47015.57,32910.899,CIGNA [1000112],CIGNA [100011201],,,68,,31970.5876,7771.48,37612.456,percent of total billed charges,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,78265.02,54785.514,CIGNA [1000112],CIGNA [100011201],,,68,,53220.2136,7771.48,62612.016,percent of total billed charges,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,20842.72,14589.904,CIGNA [1000112],CIGNA [100011201],,,68,,14173.0496,6951.04712,28554.0024,percent of total billed charges,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,18317.47,12822.229,CIGNA [1000112],CIGNA [100011201],,,68,,12455.8796,6108.876245,16505.028,percent of total billed charges,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,31259.62,21881.734,CIGNA [1000112],CIGNA [100011201],,,68,,21256.5416,7771.48,32756.756,percent of total billed charges,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,20969.38,14678.566,CIGNA [1000112],CIGNA [100011201],,,68,,14259.1784,6993.28823,20103.9144,percent of total billed charges,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20162.41,14113.687,CIGNA [1000112],CIGNA [100011201],,,68,,13710.4388,6302.75,16129.928,percent of total billed charges,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,37050.11,25935.077,CIGNA [1000112],CIGNA [100011201],,,68,,25194.0748,7771.48,35415.3928,percent of total billed charges,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,30930.47,21651.329,CIGNA [1000112],CIGNA [100011201],,,68,,21032.7196,7771.48,24744.376,percent of total billed charges,
Respiratory Neoplasms Without Cc/McC,182,MS-DRG,,,,,,,inpatient,,,24638.57,17246.999,CIGNA [1000112],CIGNA [100011201],,,68,,16754.2276,5697.87,19710.856,percent of total billed charges,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,35855.45,25098.815,CIGNA [1000112],CIGNA [100011201],,,68,,24381.706,7771.48,32163.0208,percent of total billed charges,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,22588.59,15812.013,CIGNA [1000112],CIGNA [100011201],,,68,,15360.2412,7520.46,21641.952,percent of total billed charges,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,25741.06,18018.742,CIGNA [1000112],CIGNA [100011201],,,68,,17503.9208,7771.48,32017.12,percent of total billed charges,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,11443.72,8010.604,CIGNA [1000112],CIGNA [100011201],,,68,,7781.7296,3816.48062,20343.0296,percent of total billed charges,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,21611.05,15127.735,CIGNA [1000112],CIGNA [100011201],,,68,,14695.514,7207.285175,25076.7,percent of total billed charges,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,22710.76,15897.532,CIGNA [1000112],CIGNA [100011201],,,68,,15443.3168,7574.03846,22762.5512,percent of total billed charges,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,17567.6,12297.32,CIGNA [1000112],CIGNA [100011201],,,68,,11945.968,5858.7946,17408.8024,percent of total billed charges,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,13024.23,9116.961,CIGNA [1000112],CIGNA [100011201],,,68,,8856.4764,4343.580705,13114.8608,percent of total billed charges,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,25981.01,18186.707,CIGNA [1000112],CIGNA [100011201],,,68,,17667.0868,7771.48,26703.8992,percent of total billed charges,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,18230.9,12761.63,CIGNA [1000112],CIGNA [100011201],,,68,,12397.012,6080.00515,16616.48,percent of total billed charges,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,12094.06,8465.842,CIGNA [1000112],CIGNA [100011201],,,68,,8223.9608,4033.36901,12620.4192,percent of total billed charges,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25422.94,17796.058,CIGNA [1000112],CIGNA [100011201],,,68,,17287.5992,7771.48,38181.4288,percent of total billed charges,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,23032.67,16122.869,CIGNA [1000112],CIGNA [100011201],,,68,,15662.2156,7275.91,20059.3336,percent of total billed charges,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,22301.78,15611.246,CIGNA [1000112],CIGNA [100011201],,,68,,15165.2104,7437.64363,35770.0128,percent of total billed charges,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,31940.04,22358.028,CIGNA [1000112],CIGNA [100011201],,,68,,21719.2272,7771.48,25552.032,percent of total billed charges,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,17352.2,12146.54,CIGNA [1000112],CIGNA [100011201],,,68,,11799.496,5133.51,13881.76,percent of total billed charges,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,17596.96,12317.872,CIGNA [1000112],CIGNA [100011201],,,68,,11965.9328,5868.58616,19589.2088,percent of total billed charges,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,12229.54,8560.678,CIGNA [1000112],CIGNA [100011201],,,68,,8316.0872,4078.55159,14109.8232,percent of total billed charges,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,30544.64,21381.248,CIGNA [1000112],CIGNA [100011201],,,68,,20770.3552,5734.05,24435.712,percent of total billed charges,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,23745.99,16622.193,CIGNA [1000112],CIGNA [100011201],,,68,,16147.2732,7771.48,38252.3528,percent of total billed charges,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,17630.01,12341.007,CIGNA [1000112],CIGNA [100011201],,,68,,11988.4068,5879.608335,18355.1312,percent of total billed charges,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,173078.09,121154.663,CIGNA [1000112],CIGNA [100011201],,,68,,117693.1012,7771.48,138462.472,percent of total billed charges,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,53859.21,37701.447,CIGNA [1000112],CIGNA [100011201],,,68,,36624.2628,7771.48,54390.6024,percent of total billed charges,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,inpatient,,,221306.62,154914.634,CIGNA [1000112],CIGNA [100011201],,,68,,150488.5016,7771.48,220737.7784,percent of total billed charges,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,354301.39,248010.973,CIGNA [1000112],CIGNA [100011201],,,68,,240924.9452,7771.48,283441.112,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC,216,MS-DRG,,,,,,,inpatient,,,299760.69,209832.483,CIGNA [1000112],CIGNA [100011201],,,68,,203837.2692,7771.48,239808.552,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,inpatient,,,204620.11,143234.077,CIGNA [1000112],CIGNA [100011201],,,68,,139141.6748,7771.48,163696.088,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC,219,MS-DRG,,,,,,,inpatient,,,208854.44,146198.108,CIGNA [1000112],CIGNA [100011201],,,68,,142021.0192,7771.48,167083.552,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,inpatient,,,154365.68,108055.976,CIGNA [1000112],CIGNA [100011201],,,68,,104968.6624,7771.48,123492.544,percent of total billed charges,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,181781.45,127247.015,CIGNA [1000112],CIGNA [100011201],,,68,,123611.386,7771.48,145425.16,percent of total billed charges,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,228758.84,160131.188,CIGNA [1000112],CIGNA [100011201],,,68,,155556.0112,7771.48,183007.072,percent of total billed charges,
Other Cardiothoracic Procedures Without McC,229,MS-DRG,,,,,,,inpatient,,,95347.28,66743.096,CIGNA [1000112],CIGNA [100011201],,,68,,64836.1504,7771.48,76277.824,percent of total billed charges,
Coronary Bypass With Ptca With McC,231,MS-DRG,,,,,,,inpatient,,,220697.29,154488.103,CIGNA [1000112],CIGNA [100011201],,,68,,150074.1572,7771.48,176557.832,percent of total billed charges,
Coronary Bypass With Ptca Without McC,232,MS-DRG,,,,,,,inpatient,,,203083.55,142158.485,CIGNA [1000112],CIGNA [100011201],,,68,,138096.814,7771.48,162466.84,percent of total billed charges,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,193515.4,135460.78,CIGNA [1000112],CIGNA [100011201],,,68,,131590.472,7771.48,158379.3712,percent of total billed charges,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,165546.93,115882.851,CIGNA [1000112],CIGNA [100011201],,,68,,112571.9124,7771.48,132437.544,percent of total billed charges,
Coronary Bypass Without Cardiac Catheterization With McC,235,MS-DRG,,,,,,,inpatient,,,145342.16,101739.512,CIGNA [1000112],CIGNA [100011201],,,68,,98832.6688,7771.48,119229.3232,percent of total billed charges,
Coronary Bypass Without Cardiac Catheterization Without McC,236,MS-DRG,,,,,,,inpatient,,,130227.12,91158.984,CIGNA [1000112],CIGNA [100011201],,,68,,88554.4416,7771.48,104181.696,percent of total billed charges,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,39344.02,27540.814,CIGNA [1000112],CIGNA [100011201],,,68,,26753.9336,7771.48,102059.636,percent of total billed charges,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,41409.42,28986.594,CIGNA [1000112],CIGNA [100011201],,,68,,28158.4056,7771.48,59008.768,percent of total billed charges,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC,241,MS-DRG,,,,,,,inpatient,,,19499.72,13649.804,CIGNA [1000112],CIGNA [100011201],,,68,,13259.8096,6503.15662,30594.5872,percent of total billed charges,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,76706.54,53694.578,CIGNA [1000112],CIGNA [100011201],,,68,,52160.4472,7771.48,68735.488,percent of total billed charges,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,63602.84,44521.988,CIGNA [1000112],CIGNA [100011201],,,68,,43249.9312,7771.48,50882.272,percent of total billed charges,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,60755.43,42528.801,CIGNA [1000112],CIGNA [100011201],,,68,,41313.6924,7771.48,48604.344,percent of total billed charges,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,109531.23,76671.861,CIGNA [1000112],CIGNA [100011201],,,68,,74481.2364,7771.48,99020.036,percent of total billed charges,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC,250,MS-DRG,,,,,,,inpatient,,,42609.28,29826.496,CIGNA [1000112],CIGNA [100011201],,,68,,28974.3104,7771.48,46864.5528,percent of total billed charges,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,52812.94,36969.058,CIGNA [1000112],CIGNA [100011201],,,68,,35912.7992,7771.48,42250.352,percent of total billed charges,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,100566.7,70396.69,CIGNA [1000112],CIGNA [100011201],,,68,,68385.356,7771.48,80453.36,percent of total billed charges,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,72499.37,50749.559,CIGNA [1000112],CIGNA [100011201],,,68,,49299.5716,7771.48,57999.496,percent of total billed charges,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,68903.94,48232.758,CIGNA [1000112],CIGNA [100011201],,,68,,46854.6792,7771.48,55123.152,percent of total billed charges,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13134.86,9194.402,CIGNA [1000112],CIGNA [100011201],,,68,,8931.7048,4380.47581,34319.1104,percent of total billed charges,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,20863.13,14604.191,CIGNA [1000112],CIGNA [100011201],,,68,,14186.9284,6957.853855,18073.4616,percent of total billed charges,
Cardiac Pacemaker Device Replacement With McC,258,MS-DRG,,,,,,,inpatient,,,71596.9,50117.83,CIGNA [1000112],CIGNA [100011201],,,68,,48685.892,7771.48,57277.52,percent of total billed charges,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,44827.64,31379.348,CIGNA [1000112],CIGNA [100011201],,,68,,30482.7952,7771.48,35862.112,percent of total billed charges,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,130030.35,91021.245,CIGNA [1000112],CIGNA [100011201],,,68,,88420.638,7771.48,104024.28,percent of total billed charges,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,49670.67,34769.469,CIGNA [1000112],CIGNA [100011201],,,68,,33776.0556,7771.48,39736.536,percent of total billed charges,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC,262,MS-DRG,,,,,,,inpatient,,,58341.51,40839.057,CIGNA [1000112],CIGNA [100011201],,,68,,39672.2268,7771.48,46673.208,percent of total billed charges,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,49042.27,34329.589,CIGNA [1000112],CIGNA [100011201],,,68,,33348.7436,7771.48,70820.6536,percent of total billed charges,
Aicd Lead Procedures,265,MS-DRG,,,,,,,inpatient,,,64208.05,44945.635,CIGNA [1000112],CIGNA [100011201],,,68,,43661.474,7771.48,72279.6616,percent of total billed charges,
Endovascular Cardiac Valve Replacement And Supplement Procedures With McC,266,MS-DRG,,,,,,,inpatient,,,134751.65,94326.155,CIGNA [1000112],CIGNA [100011201],,,68,,91631.122,7771.48,121389.4656,percent of total billed charges,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC,267,MS-DRG,,,,,,,inpatient,,,133372.27,93360.589,CIGNA [1000112],CIGNA [100011201],,,68,,90693.1436,7771.48,106697.816,percent of total billed charges,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,241728.99,169210.293,CIGNA [1000112],CIGNA [100011201],,,68,,164375.7132,7771.48,193383.192,percent of total billed charges,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,132639.05,92847.335,CIGNA [1000112],CIGNA [100011201],,,68,,90194.554,7771.48,106111.24,percent of total billed charges,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,135782.35,95047.645,CIGNA [1000112],CIGNA [100011201],,,68,,92331.998,7771.48,108625.88,percent of total billed charges,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,140000.81,98000.567,CIGNA [1000112],CIGNA [100011201],,,68,,95200.5508,7771.48,112000.648,percent of total billed charges,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,151532.98,106073.086,CIGNA [1000112],CIGNA [100011201],,,68,,103042.4264,7771.48,121226.384,percent of total billed charges,
Percutaneous And Other Intracardiac Procedures With McC,273,MS-DRG,,,,,,,inpatient,,,102782.81,71947.967,CIGNA [1000112],CIGNA [100011201],,,68,,69892.3108,7771.48,82226.248,percent of total billed charges,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,82201.95,57541.365,CIGNA [1000112],CIGNA [100011201],,,68,,55897.326,7771.48,65761.56,percent of total billed charges,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,183325.52,128327.864,CIGNA [1000112],CIGNA [100011201],,,68,,124661.3536,7771.48,146660.416,percent of total billed charges,
Cardiac Defibrillator Implant With McC,276,MS-DRG,,,,,,,inpatient,,,196887.28,137821.096,CIGNA [1000112],CIGNA [100011201],,,68,,133883.3504,7771.48,157509.824,percent of total billed charges,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,177791.04,124453.728,CIGNA [1000112],CIGNA [100011201],,,68,,120897.9072,7771.48,142232.832,percent of total billed charges,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,157626.97,110338.879,CIGNA [1000112],CIGNA [100011201],,,68,,107186.3396,7771.48,126101.576,percent of total billed charges,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,93744.91,65621.437,CIGNA [1000112],CIGNA [100011201],,,68,,63746.5388,7771.48,74995.928,percent of total billed charges,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31041.23,21728.861,CIGNA [1000112],CIGNA [100011201],,,68,,21108.0364,7771.48,33263.356,percent of total billed charges,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,26543.44,18580.408,CIGNA [1000112],CIGNA [100011201],,,68,,18049.5392,6744.11,21234.752,percent of total billed charges,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,23815.3,16670.71,CIGNA [1000112],CIGNA [100011201],,,68,,16194.404,5249.28,19052.24,percent of total billed charges,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,19212.47,13448.729,CIGNA [1000112],CIGNA [100011201],,,68,,13064.4796,6407.358745,39624.2256,percent of total billed charges,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,10954.07,7667.849,CIGNA [1000112],CIGNA [100011201],,,68,,7448.7676,3653.182345,15013.5976,percent of total billed charges,
Acute Myocardial Infarction- Expired Without Cc/McC,285,MS-DRG,,,,,,,inpatient,,,7163.26,5014.282,CIGNA [1000112],CIGNA [100011201],,,68,,4871.0168,2388.94721,11374.1832,percent of total billed charges,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,38892.53,27224.771,CIGNA [1000112],CIGNA [100011201],,,68,,26446.9204,7771.48,44850.3112,percent of total billed charges,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,30727.74,21509.418,CIGNA [1000112],CIGNA [100011201],,,68,,20894.8632,7771.48,24582.192,percent of total billed charges,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,28457.96,19920.572,CIGNA [1000112],CIGNA [100011201],,,68,,19351.4128,7771.48,55347.0632,percent of total billed charges,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,19767.12,13836.984,CIGNA [1000112],CIGNA [100011201],,,68,,13441.6416,6592.33452,31948.2224,percent of total billed charges,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,20727.01,14508.907,CIGNA [1000112],CIGNA [100011201],,,68,,14094.3668,6912.457835,26442.4936,percent of total billed charges,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,15225.15,10657.605,CIGNA [1000112],CIGNA [100011201],,,68,,10353.102,5077.587525,17453.3832,percent of total billed charges,
Heart Failure And Shock Without Cc/McC,293,MS-DRG,,,,,,,inpatient,,,10124.22,7086.954,CIGNA [1000112],CIGNA [100011201],,,68,,6884.4696,3376.42737,11124.936,percent of total billed charges,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,25950.27,18165.189,CIGNA [1000112],CIGNA [100011201],,,68,,17646.1836,7771.48,33198.5112,percent of total billed charges,
Cardiac Arrest- Unexplained With Cc,297,MS-DRG,,,,,,,inpatient,,,10642.36,7449.652,CIGNA [1000112],CIGNA [100011201],,,68,,7236.8048,3549.22706,14273.9616,percent of total billed charges,
Cardiac Arrest- Unexplained Without Cc/McC,298,MS-DRG,,,,,,,inpatient,,,12953.57,9067.499,CIGNA [1000112],CIGNA [100011201],,,68,,8808.4276,4151.065639,10362.856,percent of total billed charges,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,22073.95,15451.765,CIGNA [1000112],CIGNA [100011201],,,68,,15010.286,7361.662325,32781.0728,percent of total billed charges,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,21942.88,15360.016,CIGNA [1000112],CIGNA [100011201],,,68,,14921.1584,7317.95048,21692.612,percent of total billed charges,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,24649.73,17254.811,CIGNA [1000112],CIGNA [100011201],,,68,,16761.8164,5372.28,19719.784,percent of total billed charges,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,9953.04,6967.128,CIGNA [1000112],CIGNA [100011201],,,68,,6768.0672,3319.33884,23571.0848,percent of total billed charges,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16791.27,11753.889,CIGNA [1000112],CIGNA [100011201],,,68,,11418.0636,4894.02,13625.5136,percent of total billed charges,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,37676.15,26373.305,CIGNA [1000112],CIGNA [100011201],,,68,,25619.782,7771.48,30140.92,percent of total billed charges,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,16488.7,11542.09,CIGNA [1000112],CIGNA [100011201],,,68,,11212.316,5343.34,15212.1848,percent of total billed charges,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,22172.6,15520.82,CIGNA [1000112],CIGNA [100011201],,,68,,15077.368,7394.5621,30343.3136,percent of total billed charges,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,15582.95,10908.065,CIGNA [1000112],CIGNA [100011201],,,68,,10596.406,5196.913825,18770.5432,percent of total billed charges,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,19410.63,13587.441,CIGNA [1000112],CIGNA [100011201],,,68,,13199.2284,6473.445105,24438.384,percent of total billed charges,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,14290.45,10003.315,CIGNA [1000112],CIGNA [100011201],,,68,,9717.506,4765.865075,14981.1752,percent of total billed charges,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,11407.4,7985.18,CIGNA [1000112],CIGNA [100011201],,,68,,7757.032,3804.3679,11337.708,percent of total billed charges,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,11897.35,8328.145,CIGNA [1000112],CIGNA [100011201],,,68,,8090.198,3967.766225,14154.404,percent of total billed charges,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,16541.17,11578.819,CIGNA [1000112],CIGNA [100011201],,,68,,11247.9956,5516.480195,17656.0232,percent of total billed charges,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,15084.64,10559.248,CIGNA [1000112],CIGNA [100011201],,,68,,10257.5552,5030.72744,14454.3112,percent of total billed charges,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,31164.15,21814.905,CIGNA [1000112],CIGNA [100011201],,,68,,21191.622,7771.48,43636.4976,percent of total billed charges,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,18201.8,12741.26,CIGNA [1000112],CIGNA [100011201],,,68,,12377.224,6070.3003,19500.0472,percent of total billed charges,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,10045.09,7031.563,CIGNA [1000112],CIGNA [100011201],,,68,,6830.6612,3350.037515,13832.2064,percent of total billed charges,
Other Endovascular Cardiac Valve Procedures With McC,319,MS-DRG,,,,,,,inpatient,,,92577.92,64804.544,CIGNA [1000112],CIGNA [100011201],,,68,,62952.9856,7771.48,89009.62,percent of total billed charges,
Other Endovascular Cardiac Valve Procedures Without McC,320,MS-DRG,,,,,,,inpatient,,,39673.91,27771.737,CIGNA [1000112],CIGNA [100011201],,,68,,26978.2588,7771.48,46903.0544,percent of total billed charges,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,92249.33,64574.531,CIGNA [1000112],CIGNA [100011201],,,68,,62729.5444,7771.48,73799.464,percent of total billed charges,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,75877.65,53114.355,CIGNA [1000112],CIGNA [100011201],,,68,,51596.802,7771.48,60702.12,percent of total billed charges,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,116736.51,81715.557,CIGNA [1000112],CIGNA [100011201],,,68,,79380.8268,7771.48,93389.208,percent of total billed charges,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,126333.04,88433.128,CIGNA [1000112],CIGNA [100011201],,,68,,85906.4672,7771.48,101066.432,percent of total billed charges,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,inpatient,,,98701.5,69091.05,CIGNA [1000112],CIGNA [100011201],,,68,,67117.02,7771.48,78961.2,percent of total billed charges,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,64991.97,45494.379,CIGNA [1000112],CIGNA [100011201],,,68,,44194.5396,7771.48,102914.7768,percent of total billed charges,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,59110.49,41377.343,CIGNA [1000112],CIGNA [100011201],,,68,,40195.1332,7771.48,49203.0184,percent of total billed charges,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,49561.22,34692.854,CIGNA [1000112],CIGNA [100011201],,,68,,33701.6296,7771.48,39648.976,percent of total billed charges,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,78913.19,55239.233,CIGNA [1000112],CIGNA [100011201],,,68,,53660.9692,7771.48,93046.2088,percent of total billed charges,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,69586.46,48710.522,CIGNA [1000112],CIGNA [100011201],,,68,,47318.7928,7771.48,55669.168,percent of total billed charges,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,57546.85,40282.795,CIGNA [1000112],CIGNA [100011201],,,68,,39131.858,7771.48,46037.48,percent of total billed charges,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,97325,68127.5,CIGNA [1000112],CIGNA [100011201],,,68,,66181,7771.48,77860,percent of total billed charges,
Rectal Resection Without Cc/McC,334,MS-DRG,,,,,,,inpatient,,,106215.45,74350.815,CIGNA [1000112],CIGNA [100011201],,,68,,72226.506,7771.48,84972.36,percent of total billed charges,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,73034.84,51124.388,CIGNA [1000112],CIGNA [100011201],,,68,,49663.6912,7771.48,73434.7096,percent of total billed charges,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,43630.89,30541.623,CIGNA [1000112],CIGNA [100011201],,,68,,29669.0052,7771.48,42805.6736,percent of total billed charges,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,37370.19,26159.133,CIGNA [1000112],CIGNA [100011201],,,68,,25411.7292,7771.48,31105.24,percent of total billed charges,
Minor Small And Large Bowel Procedures With McC,344,MS-DRG,,,,,,,inpatient,,,23852.76,16696.932,CIGNA [1000112],CIGNA [100011201],,,68,,16219.8768,7771.48,54599.3216,percent of total billed charges,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,15908.61,11136.027,CIGNA [1000112],CIGNA [100011201],,,68,,10817.8548,5305.521435,30177.1488,percent of total billed charges,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,21216.99,14851.893,CIGNA [1000112],CIGNA [100011201],,,68,,14427.5532,7075.866165,25232.7328,percent of total billed charges,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,44922.74,31445.918,CIGNA [1000112],CIGNA [100011201],,,68,,30547.4632,7771.48,47956.7824,percent of total billed charges,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,23475.59,16432.913,CIGNA [1000112],CIGNA [100011201],,,68,,15963.4012,7771.48,25508.3232,percent of total billed charges,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,34354.1,24047.87,CIGNA [1000112],CIGNA [100011201],,,68,,23360.788,7771.48,30491.2408,percent of total billed charges,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,42230.08,29561.056,CIGNA [1000112],CIGNA [100011201],,,68,,28716.4544,7771.48,33784.064,percent of total billed charges,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,312395.2,218676.64,CIGNA [1000112],CIGNA [100011201],,,68,,212428.736,7771.48,249916.16,percent of total billed charges,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,44235.04,30964.528,CIGNA [1000112],CIGNA [100011201],,,68,,30079.8272,7771.48,35388.032,percent of total billed charges,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,51507.45,36055.215,CIGNA [1000112],CIGNA [100011201],,,68,,35025.066,7771.48,41205.96,percent of total billed charges,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,70735.47,49514.829,CIGNA [1000112],CIGNA [100011201],,,68,,48100.1196,7771.48,86434.0656,percent of total billed charges,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,77577.93,54304.551,CIGNA [1000112],CIGNA [100011201],,,68,,52752.9924,7771.48,62062.344,percent of total billed charges,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,27080.24,18956.168,CIGNA [1000112],CIGNA [100011201],,,68,,18414.5632,7771.48,27457.72,percent of total billed charges,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,23431.55,16402.085,CIGNA [1000112],CIGNA [100011201],,,68,,15933.454,7771.48,33838.8536,percent of total billed charges,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,31489.94,22042.958,CIGNA [1000112],CIGNA [100011201],,,68,,21413.1592,7771.48,25191.952,percent of total billed charges,
Major Esophageal Disorders Without Cc/McC,370,MS-DRG,,,,,,,inpatient,,,29793.71,20855.597,CIGNA [1000112],CIGNA [100011201],,,68,,20259.7228,5409.18,23834.968,percent of total billed charges,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,37215.27,26050.689,CIGNA [1000112],CIGNA [100011201],,,68,,25306.3836,7771.48,35427.5512,percent of total billed charges,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,24764.87,17335.409,CIGNA [1000112],CIGNA [100011201],,,68,,16840.1116,7435.09,20857.7352,percent of total billed charges,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,19807.89,13865.523,CIGNA [1000112],CIGNA [100011201],,,68,,13469.3652,5379.51,15846.312,percent of total billed charges,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,38795.7,27156.99,CIGNA [1000112],CIGNA [100011201],,,68,,26381.076,7771.48,42787.436,percent of total billed charges,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,40108.1,28075.67,CIGNA [1000112],CIGNA [100011201],,,68,,27273.508,7771.48,32086.48,percent of total billed charges,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,8031.54,5622.078,CIGNA [1000112],CIGNA [100011201],,,68,,5461.4472,2678.51859,17891.0856,percent of total billed charges,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,38252.31,26776.617,CIGNA [1000112],CIGNA [100011201],,,68,,26011.5708,7771.48,36841.9784,percent of total billed charges,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,30659.48,21461.636,CIGNA [1000112],CIGNA [100011201],,,68,,20848.4464,7186.19,24527.584,percent of total billed charges,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,17080.5,11956.35,CIGNA [1000112],CIGNA [100011201],,,68,,11614.74,4609.67,13664.4,percent of total billed charges,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33361.1,23352.77,CIGNA [1000112],CIGNA [100011201],,,68,,22685.548,7771.48,38994.0152,percent of total billed charges,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,34876.59,24413.613,CIGNA [1000112],CIGNA [100011201],,,68,,23716.0812,7667.34,27901.272,percent of total billed charges,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,23295.58,16306.906,CIGNA [1000112],CIGNA [100011201],,,68,,15840.9944,6456.86,18636.464,percent of total billed charges,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,19010.83,13307.581,CIGNA [1000112],CIGNA [100011201],,,68,,12927.3644,6340.111805,32922.9208,percent of total billed charges,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,17687.57,12381.299,CIGNA [1000112],CIGNA [100011201],,,68,,12027.5476,5898.804595,20109.9936,percent of total billed charges,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12268.03,8587.621,CIGNA [1000112],CIGNA [100011201],,,68,,8342.2604,4091.388005,13582.9592,percent of total billed charges,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,35037.99,24526.593,CIGNA [1000112],CIGNA [100011201],,,68,,23825.8332,7771.48,29788.08,percent of total billed charges,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,19193.48,13435.436,CIGNA [1000112],CIGNA [100011201],,,68,,13051.5664,5946.04,16245.6488,percent of total billed charges,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12403.72,8682.604,CIGNA [1000112],CIGNA [100011201],,,68,,8434.5296,4136.64062,11086.4344,percent of total billed charges,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,23697.98,16588.586,CIGNA [1000112],CIGNA [100011201],,,68,,16114.6264,7771.48,26037.2136,percent of total billed charges,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16680.62,11676.434,CIGNA [1000112],CIGNA [100011201],,,68,,11342.8216,5530.73,15811.9992,percent of total billed charges,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,35226.46,24658.522,CIGNA [1000112],CIGNA [100011201],,,68,,23953.9928,7771.48,33555.1576,percent of total billed charges,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,21027.93,14719.551,CIGNA [1000112],CIGNA [100011201],,,68,,14298.9924,6791.14,19074.5032,percent of total billed charges,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,19292.51,13504.757,CIGNA [1000112],CIGNA [100011201],,,68,,13118.9068,4700.83,15434.008,percent of total billed charges,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,31379.86,21965.902,CIGNA [1000112],CIGNA [100011201],,,68,,21338.3048,7771.48,50206.0864,percent of total billed charges,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,37379.45,26165.615,CIGNA [1000112],CIGNA [100011201],,,68,,25418.026,7771.48,30665.5112,percent of total billed charges,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,31865.55,22305.885,CIGNA [1000112],CIGNA [100011201],,,68,,21668.574,7771.48,25492.44,percent of total billed charges,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,43167.44,30217.208,CIGNA [1000112],CIGNA [100011201],,,68,,29353.8592,7771.48,56905.3648,percent of total billed charges,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,37981.98,26587.386,CIGNA [1000112],CIGNA [100011201],,,68,,25827.7464,7771.48,43275.7984,percent of total billed charges,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC,408,MS-DRG,,,,,,,inpatient,,,66496.81,46547.767,CIGNA [1000112],CIGNA [100011201],,,68,,45217.8308,7771.48,70946.2904,percent of total billed charges,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,54723.42,38306.394,CIGNA [1000112],CIGNA [100011201],,,68,,37211.9256,7771.48,43778.736,percent of total billed charges,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC,410,MS-DRG,,,,,,,inpatient,,,49332.9,34533.03,CIGNA [1000112],CIGNA [100011201],,,68,,33546.372,7771.48,39466.32,percent of total billed charges,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,inpatient,,,94854.82,66398.374,CIGNA [1000112],CIGNA [100011201],,,68,,64501.2776,7771.48,75883.856,percent of total billed charges,
Cholecystectomy Except By Laparoscope Without C.D.E. With McC,414,MS-DRG,,,,,,,inpatient,,,158479.92,110935.944,CIGNA [1000112],CIGNA [100011201],,,68,,107766.3456,7771.48,126783.936,percent of total billed charges,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/McC,416,MS-DRG,,,,,,,inpatient,,,36054.28,25237.996,CIGNA [1000112],CIGNA [100011201],,,68,,24516.9104,7771.48,28843.424,percent of total billed charges,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,57775.9,40443.13,CIGNA [1000112],CIGNA [100011201],,,68,,39287.612,7771.48,48157.396,percent of total billed charges,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,45650.74,31955.518,CIGNA [1000112],CIGNA [100011201],,,68,,31042.5032,7771.48,36520.592,percent of total billed charges,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,40583.9,28408.73,CIGNA [1000112],CIGNA [100011201],,,68,,27597.052,7771.48,32467.12,percent of total billed charges,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,43141.15,30198.805,CIGNA [1000112],CIGNA [100011201],,,68,,29335.982,7771.48,71515.7088,percent of total billed charges,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,126455.95,88519.165,CIGNA [1000112],CIGNA [100011201],,,68,,85990.046,7771.48,101164.76,percent of total billed charges,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,inpatient,,,66431.87,46502.309,CIGNA [1000112],CIGNA [100011201],,,68,,45173.6716,7771.48,53145.496,percent of total billed charges,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,37750.2,26425.14,CIGNA [1000112],CIGNA [100011201],,,68,,25670.136,7771.48,39699.2024,percent of total billed charges,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,22206.74,15544.718,CIGNA [1000112],CIGNA [100011201],,,68,,15100.5832,7405.94779,21676.4008,percent of total billed charges,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,9888.24,6921.768,CIGNA [1000112],CIGNA [100011201],,,68,,6724.0032,3297.72804,14111.8496,percent of total billed charges,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41222.48,28855.736,CIGNA [1000112],CIGNA [100011201],,,68,,28031.2864,7771.48,36971.668,percent of total billed charges,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,21857.06,15299.942,CIGNA [1000112],CIGNA [100011201],,,68,,14862.8008,7289.32951,22849.6864,percent of total billed charges,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,34142.65,23899.855,CIGNA [1000112],CIGNA [100011201],,,68,,23217.002,7771.48,33715.2432,percent of total billed charges,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,18774.77,13142.339,CIGNA [1000112],CIGNA [100011201],,,68,,12766.8436,6109.56,17431.0928,percent of total billed charges,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,12926.06,9048.242,CIGNA [1000112],CIGNA [100011201],,,68,,8789.7208,4310.84101,12464.3864,percent of total billed charges,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,33617.1,23531.97,CIGNA [1000112],CIGNA [100011201],,,68,,22859.628,7771.48,38305.0392,percent of total billed charges,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,18826.25,13178.375,CIGNA [1000112],CIGNA [100011201],,,68,,12801.85,6278.554375,19579.0768,percent of total billed charges,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,9263.58,6484.506,CIGNA [1000112],CIGNA [100011201],,,68,,6299.2344,3089.40393,14237.4864,percent of total billed charges,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,36248.92,25374.244,CIGNA [1000112],CIGNA [100011201],,,68,,24649.2656,7771.48,34134.708,percent of total billed charges,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,33226.4,23258.48,CIGNA [1000112],CIGNA [100011201],,,68,,22593.952,7771.48,26581.12,percent of total billed charges,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,28308.58,19816.006,CIGNA [1000112],CIGNA [100011201],,,68,,19249.8344,5905.53,22646.864,percent of total billed charges,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,114168.82,79918.174,CIGNA [1000112],CIGNA [100011201],,,68,,77634.7976,7771.48,91335.056,percent of total billed charges,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,93512.08,65458.456,CIGNA [1000112],CIGNA [100011201],,,68,,63588.2144,7771.48,74809.664,percent of total billed charges,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With McC,456,MS-DRG,,,,,,,inpatient,,,202351.8,141646.26,CIGNA [1000112],CIGNA [100011201],,,68,,137599.224,7771.48,171607.7104,percent of total billed charges,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,152088.75,106462.125,CIGNA [1000112],CIGNA [100011201],,,68,,103420.35,7771.48,121671,percent of total billed charges,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,114206.41,79944.487,CIGNA [1000112],CIGNA [100011201],,,68,,77660.3588,7771.48,91365.128,percent of total billed charges,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,70294.35,49206.045,CIGNA [1000112],CIGNA [100011201],,,68,,47800.158,7771.48,109439.7848,percent of total billed charges,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,25826.71,18078.697,CIGNA [1000112],CIGNA [100011201],,,68,,17562.1628,7771.48,59750.4304,percent of total billed charges,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,10589.98,7412.986,CIGNA [1000112],CIGNA [100011201],,,68,,7201.1864,3531.75833,35176.2776,percent of total billed charges,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,134518.68,94163.076,CIGNA [1000112],CIGNA [100011201],,,68,,91472.7024,7771.48,107614.944,percent of total billed charges,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,95919.47,67143.629,CIGNA [1000112],CIGNA [100011201],,,68,,65225.2396,7771.48,76735.576,percent of total billed charges,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,68797.87,48158.509,CIGNA [1000112],CIGNA [100011201],,,68,,46782.5516,7771.48,55038.296,percent of total billed charges,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,54280.26,37996.182,CIGNA [1000112],CIGNA [100011201],,,68,,36910.5768,7771.48,66232.884,percent of total billed charges,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,53419.21,37393.447,CIGNA [1000112],CIGNA [100011201],,,68,,36325.0628,7771.48,42735.368,percent of total billed charges,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68987.67,48291.369,CIGNA [1000112],CIGNA [100011201],,,68,,46911.6156,7771.48,98422.248,percent of total billed charges,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,77778.52,54444.964,CIGNA [1000112],CIGNA [100011201],,,68,,52889.3936,7771.48,62222.816,percent of total billed charges,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,54869.65,38408.755,CIGNA [1000112],CIGNA [100011201],,,68,,37311.362,7771.48,47968.9408,percent of total billed charges,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,71787.88,50251.516,CIGNA [1000112],CIGNA [100011201],,,68,,48815.7584,7771.48,90871.8816,percent of total billed charges,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,33747.79,23623.453,CIGNA [1000112],CIGNA [100011201],,,68,,22948.4972,7771.48,43711.4744,percent of total billed charges,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,89768.8,62838.16,CIGNA [1000112],CIGNA [100011201],,,68,,61042.784,7771.48,71815.04,percent of total billed charges,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,65676.03,45973.221,CIGNA [1000112],CIGNA [100011201],,,68,,44659.7004,7771.48,52540.824,percent of total billed charges,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,26493.14,18545.198,CIGNA [1000112],CIGNA [100011201],,,68,,18015.3352,7771.48,35982.7848,percent of total billed charges,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,50028.86,35020.202,CIGNA [1000112],CIGNA [100011201],,,68,,34019.6248,7771.48,59596.424,percent of total billed charges,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,54052.44,37836.708,CIGNA [1000112],CIGNA [100011201],,,68,,36755.6592,7771.48,43241.952,percent of total billed charges,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,42724.18,29906.926,CIGNA [1000112],CIGNA [100011201],,,68,,29052.4424,7771.48,34179.344,percent of total billed charges,
Knee Procedures With Principal Diagnosis Of Infection With McC,485,MS-DRG,,,,,,,inpatient,,,78688.59,55082.013,CIGNA [1000112],CIGNA [100011201],,,68,,53508.2412,7771.48,65323.0304,percent of total billed charges,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,38633.42,27043.394,CIGNA [1000112],CIGNA [100011201],,,68,,26270.7256,7771.48,42973.8648,percent of total billed charges,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,68635.57,48044.899,CIGNA [1000112],CIGNA [100011201],,,68,,46672.1876,7771.48,54908.456,percent of total billed charges,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,35436.81,24805.767,CIGNA [1000112],CIGNA [100011201],,,68,,24097.0308,7771.48,28349.448,percent of total billed charges,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,77413.36,54189.352,CIGNA [1000112],CIGNA [100011201],,,68,,52641.0848,7771.48,71957.464,percent of total billed charges,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,79988.8,55992.16,CIGNA [1000112],CIGNA [100011201],,,68,,54392.384,7771.48,63991.04,percent of total billed charges,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,52007.74,36405.418,CIGNA [1000112],CIGNA [100011201],,,68,,35365.2632,7771.48,41606.192,percent of total billed charges,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC,495,MS-DRG,,,,,,,inpatient,,,55215.82,38651.074,CIGNA [1000112],CIGNA [100011201],,,68,,37546.7576,7771.48,71335.3592,percent of total billed charges,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC,499,MS-DRG,,,,,,,inpatient,,,24343.66,17040.562,CIGNA [1000112],CIGNA [100011201],,,68,,16553.6888,7771.48,23522.4512,percent of total billed charges,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,43692.12,30584.484,CIGNA [1000112],CIGNA [100011201],,,68,,29710.6416,7771.48,64206.484,percent of total billed charges,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,30673.94,21471.758,CIGNA [1000112],CIGNA [100011201],,,68,,20858.2792,7771.48,36169.2136,percent of total billed charges,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,41306.96,28914.872,CIGNA [1000112],CIGNA [100011201],,,68,,28088.7328,7771.48,53628.676,percent of total billed charges,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,37180.29,26026.203,CIGNA [1000112],CIGNA [100011201],,,68,,25282.5972,7771.48,35575.4784,percent of total billed charges,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,63266.34,44286.438,CIGNA [1000112],CIGNA [100011201],,,68,,43021.1112,7771.48,50613.072,percent of total billed charges,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,57782.59,40447.813,CIGNA [1000112],CIGNA [100011201],,,68,,39292.1612,7771.48,57914.512,percent of total billed charges,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,39749.27,27824.489,CIGNA [1000112],CIGNA [100011201],,,68,,27029.5036,7771.48,39745.8096,percent of total billed charges,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,26213.06,18349.142,CIGNA [1000112],CIGNA [100011201],,,68,,17824.8808,7771.48,30507.452,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,64680.35,45276.245,CIGNA [1000112],CIGNA [100011201],,,68,,43982.638,7771.48,62660.3408,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,33187.16,23231.012,CIGNA [1000112],CIGNA [100011201],,,68,,22567.2688,7771.48,40763.0624,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,28664.41,20065.087,CIGNA [1000112],CIGNA [100011201],,,68,,19491.7988,7771.48,30246.0464,percent of total billed charges,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,52006.98,36404.886,CIGNA [1000112],CIGNA [100011201],,,68,,35364.7464,7771.48,72622.1232,percent of total billed charges,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,60945.78,42662.046,CIGNA [1000112],CIGNA [100011201],,,68,,41443.1304,7771.48,48756.624,percent of total billed charges,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,27733.63,19413.541,CIGNA [1000112],CIGNA [100011201],,,68,,18858.8684,7771.48,29040.3384,percent of total billed charges,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,64155.47,44908.829,CIGNA [1000112],CIGNA [100011201],,,68,,43625.7196,7771.48,59061.4544,percent of total billed charges,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59467.45,41627.215,CIGNA [1000112],CIGNA [100011201],,,68,,40437.866,7771.48,47573.96,percent of total billed charges,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,24348.24,17043.768,CIGNA [1000112],CIGNA [100011201],,,68,,16556.8032,7771.48,26949.0936,percent of total billed charges,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,14748.61,10324.027,CIGNA [1000112],CIGNA [100011201],,,68,,10029.0548,4918.661435,16432.0776,percent of total billed charges,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,34525.72,24168.004,CIGNA [1000112],CIGNA [100011201],,,68,,23477.4896,7771.48,40987.9928,percent of total billed charges,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,27528.18,19269.726,CIGNA [1000112],CIGNA [100011201],,,68,,18719.1624,7771.48,26229.7216,percent of total billed charges,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,28046.03,19632.221,CIGNA [1000112],CIGNA [100011201],,,68,,19071.3004,7771.48,37790.3336,percent of total billed charges,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,29133.49,20393.443,CIGNA [1000112],CIGNA [100011201],,,68,,19810.7732,7548.68,23306.792,percent of total billed charges,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,17251.52,12076.064,CIGNA [1000112],CIGNA [100011201],,,68,,11731.0336,5616.11,15313.5048,percent of total billed charges,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,10607.77,7425.439,CIGNA [1000112],CIGNA [100011201],,,68,,7213.2836,3537.691295,51201.0488,percent of total billed charges,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,22929.4,16050.58,CIGNA [1000112],CIGNA [100011201],,,68,,15591.992,7646.9549,23459.6328,percent of total billed charges,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,15898.64,11129.048,CIGNA [1000112],CIGNA [100011201],,,68,,10811.0752,5302.19644,15120.9968,percent of total billed charges,
Septic Arthritis Without Cc/McC,550,MS-DRG,,,,,,,inpatient,,,13751.03,9625.721,CIGNA [1000112],CIGNA [100011201],,,68,,9350.7004,4585.968505,17469.5944,percent of total billed charges,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,34050.51,23835.357,CIGNA [1000112],CIGNA [100011201],,,68,,23154.3468,7771.48,34576.4632,percent of total billed charges,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,21070.26,14749.182,CIGNA [1000112],CIGNA [100011201],,,68,,14327.7768,6815.74,19530.4432,percent of total billed charges,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,37105.01,25973.507,CIGNA [1000112],CIGNA [100011201],,,68,,25231.4068,7771.48,29684.008,percent of total billed charges,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,33214.93,23250.451,CIGNA [1000112],CIGNA [100011201],,,68,,22586.1524,5718.85,26571.944,percent of total billed charges,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC,555,MS-DRG,,,,,,,inpatient,,,16910.44,11837.308,CIGNA [1000112],CIGNA [100011201],,,68,,11499.0992,5639.63174,27285.476,percent of total billed charges,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,38978.42,27284.894,CIGNA [1000112],CIGNA [100011201],,,68,,26505.3256,5833.89,31182.736,percent of total billed charges,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,25775.81,18043.067,CIGNA [1000112],CIGNA [100011201],,,68,,17527.5508,7771.48,31403.1208,percent of total billed charges,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,17322.32,12125.624,CIGNA [1000112],CIGNA [100011201],,,68,,11779.1776,5776.99372,17504.0432,percent of total billed charges,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,46066.43,32246.501,CIGNA [1000112],CIGNA [100011201],,,68,,31325.1724,7771.48,37612.0104,percent of total billed charges,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,43659.99,30561.993,CIGNA [1000112],CIGNA [100011201],,,68,,29688.7932,7771.48,34927.992,percent of total billed charges,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,35419.71,24793.797,CIGNA [1000112],CIGNA [100011201],,,68,,24085.4028,5723.92,28335.768,percent of total billed charges,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,23360.4,16352.28,CIGNA [1000112],CIGNA [100011201],,,68,,15885.072,7771.48,29660.4168,percent of total billed charges,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,23376.03,16363.221,CIGNA [1000112],CIGNA [100011201],,,68,,15895.7004,6300.58,18700.824,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,24152.97,16907.079,CIGNA [1000112],CIGNA [100011201],,,68,,16424.0196,7771.48,31798.2688,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,26103.05,18272.135,CIGNA [1000112],CIGNA [100011201],,,68,,17750.074,7280.97,20882.44,percent of total billed charges,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,12203.73,8542.611,CIGNA [1000112],CIGNA [100011201],,,68,,8298.5364,4069.943955,15157.472,percent of total billed charges,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,58121.61,40685.127,CIGNA [1000112],CIGNA [100011201],,,68,,39522.6948,7771.48,61002.7456,percent of total billed charges,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,22908.56,16035.992,CIGNA [1000112],CIGNA [100011201],,,68,,15577.8208,7640.00476,33938.1472,percent of total billed charges,
Skin Debridement Without Cc/McC,572,MS-DRG,,,,,,,inpatient,,,34042.21,23829.547,CIGNA [1000112],CIGNA [100011201],,,68,,23148.7028,7771.48,27233.768,percent of total billed charges,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,40320.12,28224.084,CIGNA [1000112],CIGNA [100011201],,,68,,27417.6816,7771.48,124781.6592,percent of total billed charges,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,31675.49,22172.843,CIGNA [1000112],CIGNA [100011201],,,68,,21539.3332,7771.48,70208.6808,percent of total billed charges,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC,575,MS-DRG,,,,,,,inpatient,,,33248.67,23274.069,CIGNA [1000112],CIGNA [100011201],,,68,,22609.0956,7771.48,40457.076,percent of total billed charges,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,inpatient,,,22694.73,15886.311,CIGNA [1000112],CIGNA [100011201],,,68,,15432.4164,7568.692455,53954.9264,percent of total billed charges,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,47774,33441.8,CIGNA [1000112],CIGNA [100011201],,,68,,32486.32,7771.48,66042.4024,percent of total billed charges,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,21385.31,14969.717,CIGNA [1000112],CIGNA [100011201],,,68,,14542.0108,7132.000885,35926.0456,percent of total billed charges,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,107178.51,75024.957,CIGNA [1000112],CIGNA [100011201],,,68,,72881.3868,7771.48,85742.808,percent of total billed charges,
Breast Biopsy- Local Excision And Other Breast Procedures Without Cc/McC,585,MS-DRG,,,,,,,inpatient,,,37278.64,26095.048,CIGNA [1000112],CIGNA [100011201],,,68,,25349.4752,7771.48,40224.04,percent of total billed charges,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,53897.07,37727.949,CIGNA [1000112],CIGNA [100011201],,,68,,36650.0076,7771.48,43117.656,percent of total billed charges,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,22540.18,15778.126,CIGNA [1000112],CIGNA [100011201],,,68,,15327.3224,5923.61,18032.144,percent of total billed charges,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,26958.01,18870.607,CIGNA [1000112],CIGNA [100011201],,,68,,18331.4468,7157.25,21905.384,percent of total billed charges,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,36927.76,25849.432,CIGNA [1000112],CIGNA [100011201],,,68,,25110.8768,7771.48,35593.716,percent of total billed charges,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,9105.56,6373.892,CIGNA [1000112],CIGNA [100011201],,,68,,6191.7808,3036.70426,21862.8296,percent of total billed charges,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,5148.62,3604.034,CIGNA [1000112],CIGNA [100011201],,,68,,3501.0616,1717.06477,12148.268,percent of total billed charges,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,21201.17,14840.819,CIGNA [1000112],CIGNA [100011201],,,68,,14416.7956,7070.590195,29775.9216,percent of total billed charges,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,14711.96,10298.372,CIGNA [1000112],CIGNA [100011201],,,68,,10004.1328,4906.43866,17850.5576,percent of total billed charges,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,29329.16,20530.412,CIGNA [1000112],CIGNA [100011201],,,68,,19943.8288,7771.48,30106.2248,percent of total billed charges,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21984.9,15389.43,CIGNA [1000112],CIGNA [100011201],,,68,,14949.732,6578.42,18717.8568,percent of total billed charges,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,26207.89,18345.523,CIGNA [1000112],CIGNA [100011201],,,68,,17821.3652,7771.48,32627.0664,percent of total billed charges,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,18364.58,12855.206,CIGNA [1000112],CIGNA [100011201],,,68,,12487.9144,5973.54,17514.1752,percent of total billed charges,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,63303.79,44312.653,CIGNA [1000112],CIGNA [100011201],,,68,,43046.5772,7771.48,78318.3336,percent of total billed charges,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,33293.26,23305.282,CIGNA [1000112],CIGNA [100011201],,,68,,22639.4168,7771.48,39154.1008,percent of total billed charges,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,inpatient,,,47713.27,33399.289,CIGNA [1000112],CIGNA [100011201],,,68,,32445.0236,7771.48,38170.616,percent of total billed charges,
O.R. Procedures For Obesity Without Cc/McC,621,MS-DRG,,,,,,,inpatient,,,43994.97,30796.479,CIGNA [1000112],CIGNA [100011201],,,68,,29916.5796,7771.48,35195.976,percent of total billed charges,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,39685.45,27779.815,CIGNA [1000112],CIGNA [100011201],,,68,,26986.106,7771.48,75868.416,percent of total billed charges,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,19840.3,13888.21,CIGNA [1000112],CIGNA [100011201],,,68,,13491.404,6616.74005,38785.296,percent of total billed charges,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,624,MS-DRG,,,,,,,inpatient,,,15962.42,11173.694,CIGNA [1000112],CIGNA [100011201],,,68,,10854.4456,5323.46707,20326.8184,percent of total billed charges,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,76735.34,53714.738,CIGNA [1000112],CIGNA [100011201],,,68,,52180.0312,7771.48,79967.8232,percent of total billed charges,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,36824.85,25777.395,CIGNA [1000112],CIGNA [100011201],,,68,,25040.898,7771.48,45596.0264,percent of total billed charges,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,27285.79,19100.053,CIGNA [1000112],CIGNA [100011201],,,68,,18554.3372,7771.48,29510.4632,percent of total billed charges,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,17323.96,12126.772,CIGNA [1000112],CIGNA [100011201],,,68,,11780.2928,5777.54066,18586.1408,percent of total billed charges,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,11395.93,7977.151,CIGNA [1000112],CIGNA [100011201],,,68,,7749.2324,3800.542655,12697.4224,percent of total billed charges,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,21542.6,15079.82,CIGNA [1000112],CIGNA [100011201],,,68,,14648.968,7184.4571,26912.6184,percent of total billed charges,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,14225.97,9958.179,CIGNA [1000112],CIGNA [100011201],,,68,,9673.6596,4744.360995,15836.316,percent of total billed charges,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,13622.93,9536.051,CIGNA [1000112],CIGNA [100011201],,,68,,9263.5924,4543.247155,25149.6504,percent of total billed charges,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,60349.49,42244.643,CIGNA [1000112],CIGNA [100011201],,,68,,41037.6532,7771.48,48279.592,percent of total billed charges,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,13236.15,9265.305,CIGNA [1000112],CIGNA [100011201],,,68,,9000.582,4414.256025,20942.844,percent of total billed charges,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13028.88,9120.216,CIGNA [1000112],CIGNA [100011201],,,68,,8859.6384,4345.13148,15785.656,percent of total billed charges,
Major Bladder Procedures Without Cc/McC,655,MS-DRG,,,,,,,inpatient,,,55359.22,38751.454,CIGNA [1000112],CIGNA [100011201],,,68,,37644.2696,7771.48,44287.376,percent of total billed charges,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,47307.79,33115.453,CIGNA [1000112],CIGNA [100011201],,,68,,32169.2972,7771.48,66014.0328,percent of total billed charges,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,42988.03,30091.621,CIGNA [1000112],CIGNA [100011201],,,68,,29231.8604,7771.48,37042.592,percent of total billed charges,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,30491.37,21343.959,CIGNA [1000112],CIGNA [100011201],,,68,,20734.1316,7771.48,52366.2288,percent of total billed charges,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,26889.16,18822.412,CIGNA [1000112],CIGNA [100011201],,,68,,18284.6288,7771.48,27151.7336,percent of total billed charges,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,19523.55,13666.485,CIGNA [1000112],CIGNA [100011201],,,68,,13276.014,6511.103925,20803.0224,percent of total billed charges,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,57156.94,40009.858,CIGNA [1000112],CIGNA [100011201],,,68,,38866.7192,7771.48,63211.5216,percent of total billed charges,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,29787.18,20851.026,CIGNA [1000112],CIGNA [100011201],,,68,,20255.2824,7771.48,30949.2072,percent of total billed charges,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,15013.42,10509.394,CIGNA [1000112],CIGNA [100011201],,,68,,10209.1256,5006.97557,21881.0672,percent of total billed charges,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,28865.76,20206.032,CIGNA [1000112],CIGNA [100011201],,,68,,19628.7168,7771.48,69574.4176,percent of total billed charges,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,28047.28,19633.096,CIGNA [1000112],CIGNA [100011201],,,68,,19072.1504,7771.48,33378.8608,percent of total billed charges,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,51984.11,36388.877,CIGNA [1000112],CIGNA [100011201],,,68,,35349.1948,7771.48,59091.8504,percent of total billed charges,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,30494.67,21346.269,CIGNA [1000112],CIGNA [100011201],,,68,,20736.3756,7771.48,31358.54,percent of total billed charges,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,12447.8,8713.46,CIGNA [1000112],CIGNA [100011201],,,68,,8464.504,4151.3413,19364.2784,percent of total billed charges,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,72572.36,50800.652,CIGNA [1000112],CIGNA [100011201],,,68,,49349.2048,7771.48,84906.16,percent of total billed charges,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,49815.27,34870.689,CIGNA [1000112],CIGNA [100011201],,,68,,33874.3836,7771.48,46775.3912,percent of total billed charges,
Other Kidney And Urinary Tract Procedures Without Cc/McC,675,MS-DRG,,,,,,,inpatient,,,67065.03,46945.521,CIGNA [1000112],CIGNA [100011201],,,68,,45604.2204,7771.48,53652.024,percent of total billed charges,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25198.22,17638.754,CIGNA [1000112],CIGNA [100011201],,,68,,17134.7896,7771.48,30436.528,percent of total billed charges,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,16815.75,11771.025,CIGNA [1000112],CIGNA [100011201],,,68,,11434.71,5608.052625,18012.6696,percent of total billed charges,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,11199.54,7839.678,CIGNA [1000112],CIGNA [100011201],,,68,,7615.6872,3735.04659,12310.38,percent of total billed charges,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,17030.3,11921.21,CIGNA [1000112],CIGNA [100011201],,,68,,11580.604,5679.60505,38209.7984,percent of total billed charges,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,10555.37,7388.759,CIGNA [1000112],CIGNA [100011201],,,68,,7177.6516,3520.215895,21329.8864,percent of total billed charges,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,21612.22,15128.554,CIGNA [1000112],CIGNA [100011201],,,68,,14696.3096,7207.67537,23716.9856,percent of total billed charges,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,14540.91,10178.637,CIGNA [1000112],CIGNA [100011201],,,68,,9887.8188,4849.393485,16263.8864,percent of total billed charges,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,27273.94,19091.758,CIGNA [1000112],CIGNA [100011201],,,68,,18546.2792,7771.48,29794.1592,percent of total billed charges,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,11406.89,7984.823,CIGNA [1000112],CIGNA [100011201],,,68,,7756.6852,3804.197815,15834.2896,percent of total billed charges,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,22314.56,15620.192,CIGNA [1000112],CIGNA [100011201],,,68,,15173.9008,7441.90576,22851.7128,percent of total billed charges,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,14767.92,10337.544,CIGNA [1000112],CIGNA [100011201],,,68,,10042.1856,4925.10132,14016.6088,percent of total billed charges,
Urethral Stricture,697,MS-DRG,,,,,,,inpatient,,,14675.76,10273.032,CIGNA [1000112],CIGNA [100011201],,,68,,9979.5168,4894.36596,20300.4752,percent of total billed charges,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,24798.67,17359.069,CIGNA [1000112],CIGNA [100011201],,,68,,16863.0956,7771.48,34061.7576,percent of total billed charges,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,17120.52,11984.364,CIGNA [1000112],CIGNA [100011201],,,68,,11641.9536,5709.69342,20665.2272,percent of total billed charges,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,41107.29,28775.103,CIGNA [1000112],CIGNA [100011201],,,68,,27952.9572,5388.92,32885.832,percent of total billed charges,
Major Male Pelvic Procedures With Cc/McC,707,MS-DRG,,,,,,,inpatient,,,35017.36,24512.152,CIGNA [1000112],CIGNA [100011201],,,68,,23811.8048,7771.48,39322.292,percent of total billed charges,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,31613.04,22129.128,CIGNA [1000112],CIGNA [100011201],,,68,,21496.8672,7771.48,30039.3536,percent of total billed charges,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,20964.14,14674.898,CIGNA [1000112],CIGNA [100011201],,,68,,14255.6152,6991.54069,45533.208,percent of total billed charges,
Penis Procedures Without Cc/McC,710,MS-DRG,,,,,,,inpatient,,,68393.44,47875.408,CIGNA [1000112],CIGNA [100011201],,,68,,46507.5392,7771.48,54714.752,percent of total billed charges,
Testes Procedures With Cc/McC,711,MS-DRG,,,,,,,inpatient,,,36907.35,25835.145,CIGNA [1000112],CIGNA [100011201],,,68,,25096.998,7771.48,38716.3984,percent of total billed charges,
Testes Procedures Without Cc/McC,712,MS-DRG,,,,,,,inpatient,,,18463.04,12924.128,CIGNA [1000112],CIGNA [100011201],,,68,,12554.8672,6157.42384,21674.3744,percent of total billed charges,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,14941.94,10459.358,CIGNA [1000112],CIGNA [100011201],,,68,,10160.5192,4983.13699,29299.7176,percent of total billed charges,
Transurethral Prostatectomy Without Cc/McC,714,MS-DRG,,,,,,,inpatient,,,10164.77,7115.339,CIGNA [1000112],CIGNA [100011201],,,68,,6912.0436,3389.950795,19040.0544,percent of total billed charges,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC,715,MS-DRG,,,,,,,inpatient,,,36701.12,25690.784,CIGNA [1000112],CIGNA [100011201],,,68,,24956.7616,7771.48,45760.1648,percent of total billed charges,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,23580.89,16506.623,CIGNA [1000112],CIGNA [100011201],,,68,,16035.0052,7771.48,37597.8256,percent of total billed charges,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC,718,MS-DRG,,,,,,,inpatient,,,27747.61,19423.327,CIGNA [1000112],CIGNA [100011201],,,68,,18868.3748,7771.48,24961.1952,percent of total billed charges,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,48176.72,33723.704,CIGNA [1000112],CIGNA [100011201],,,68,,32760.1696,7771.48,38541.376,percent of total billed charges,
Benign Prostatic Hypertrophy With McC,725,MS-DRG,,,,,,,inpatient,,,31783.16,22248.212,CIGNA [1000112],CIGNA [100011201],,,68,,21612.5488,7771.48,25595.4584,percent of total billed charges,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,10731.22,7511.854,CIGNA [1000112],CIGNA [100011201],,,68,,7297.2296,3578.86187,15082.4952,percent of total billed charges,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,9268.85,6488.195,CIGNA [1000112],CIGNA [100011201],,,68,,6302.818,3091.161475,16557.7144,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC,739,MS-DRG,,,,,,,inpatient,,,70791.15,49553.805,CIGNA [1000112],CIGNA [100011201],,,68,,48137.982,7771.48,80664.9048,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,inpatient,,,61565.64,43095.948,CIGNA [1000112],CIGNA [100011201],,,68,,41864.6352,7771.48,49252.512,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC,741,MS-DRG,,,,,,,inpatient,,,66917.01,46841.907,CIGNA [1000112],CIGNA [100011201],,,68,,45503.5668,7771.48,53533.608,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,24878.38,17414.866,CIGNA [1000112],CIGNA [100011201],,,68,,16917.2984,7771.48,37014.2224,percent of total billed charges,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,27909.66,19536.762,CIGNA [1000112],CIGNA [100011201],,,68,,18978.5688,7771.48,24288.4304,percent of total billed charges,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,16030.6,11221.42,CIGNA [1000112],CIGNA [100011201],,,68,,10900.808,5346.2051,19354.1464,percent of total billed charges,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,22664.36,15865.052,CIGNA [1000112],CIGNA [100011201],,,68,,15411.7648,7558.56406,22495.0664,percent of total billed charges,
Infections- Female Reproductive System With McC,757,MS-DRG,,,,,,,inpatient,,,15549.35,10884.545,CIGNA [1000112],CIGNA [100011201],,,68,,10573.558,5185.708225,28677.6128,percent of total billed charges,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,10151.59,7106.113,CIGNA [1000112],CIGNA [100011201],,,68,,6903.0812,3385.555265,20655.0952,percent of total billed charges,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,10881.96,7617.372,CIGNA [1000112],CIGNA [100011201],,,68,,7399.7328,3629.13366,19970.172,percent of total billed charges,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14849.95,10394.965,CIGNA [1000112],CIGNA [100011201],,,68,,10097.966,4952.458325,13906.65298,percent of total billed charges,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,25190.93,17633.651,CIGNA [1000112],CIGNA [100011201],,,68,,17129.8324,7771.48,28156.828,percent of total billed charges,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,6415.51,4490.857,CIGNA [1000112],CIGNA [100011201],,,68,,4362.5468,2139.572585,21802.0376,percent of total billed charges,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,10227.7,7159.39,CIGNA [1000112],CIGNA [100011201],,,68,,6954.836,3410.93795,14456.3376,percent of total billed charges,
Abortion Without D&C,779,MS-DRG,,,,,,,inpatient,,,13854.84,9698.388,CIGNA [1000112],CIGNA [100011201],,,68,,9421.2912,4620.58914,18940.7608,percent of total billed charges,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,19969.28,13978.496,CIGNA [1000112],CIGNA [100011201],,,68,,13579.1104,6659.75488,23129.64586,percent of total billed charges,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,17660.24,12362.168,CIGNA [1000112],CIGNA [100011201],,,68,,12008.9632,5889.69004,14128.192,percent of total billed charges,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,16297.53,11408.271,CIGNA [1000112],CIGNA [100011201],,,68,,11082.3204,5435.226255,13038.024,percent of total billed charges,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,19789.47,13852.629,CIGNA [1000112],CIGNA [100011201],,,68,,13456.8396,6599.788245,20332.32622,percent of total billed charges,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,17268.46,12087.922,CIGNA [1000112],CIGNA [100011201],,,68,,11742.5528,5759.03141,13814.768,percent of total billed charges,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,16414.17,11489.919,CIGNA [1000112],CIGNA [100011201],,,68,,11161.6356,5474.125695,13131.336,percent of total billed charges,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,4752.37,3326.659,CIGNA [1000112],CIGNA [100011201],,,68,,3231.6116,1584.915395,22641.16608,percent of total billed charges,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,54759.69,38331.783,CIGNA [1000112],CIGNA [100011201],,,68,,37236.5892,2909,73865.99995,percent of total billed charges,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39693.75,27785.625,CIGNA [1000112],CIGNA [100011201],,,68,,26991.75,2909,50556.23959,percent of total billed charges,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,7967.7,5577.39,CIGNA [1000112],CIGNA [100011201],,,68,,5418.036,2657.22795,30643.57784,percent of total billed charges,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,10068.5,7047.95,CIGNA [1000112],CIGNA [100011201],,,68,,6846.58,2909,51923.98297,percent of total billed charges,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5320.51,3724.357,CIGNA [1000112],CIGNA [100011201],,,68,,3617.9468,1774.390085,18604.71546,percent of total billed charges,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4248.78,2974.146,CIGNA [1000112],CIGNA [100011201],,,68,,2889.1704,1378.34,7947.23,percent of total billed charges,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,9202.02,6441.414,CIGNA [1000112],CIGNA [100011201],,,68,,6257.3736,3068.87367,12322.49451,percent of total billed charges,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,inpatient,,,55562.6,38893.82,CIGNA [1000112],CIGNA [100011201],,,68,,37782.568,7771.48,59041.1904,percent of total billed charges,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,36233.96,25363.772,CIGNA [1000112],CIGNA [100011201],,,68,,24639.0928,7771.48,28987.168,percent of total billed charges,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,14129.33,9890.531,CIGNA [1000112],CIGNA [100011201],,,68,,9607.9444,4712.131555,12691.01849,percent of total billed charges,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13166.38,9216.466,CIGNA [1000112],CIGNA [100011201],,,68,,8953.1384,4390.98773,10533.104,percent of total billed charges,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,12520.32,8764.224,CIGNA [1000112],CIGNA [100011201],,,68,,8513.8176,4175.52672,10016.256,percent of total billed charges,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,50163.84,35114.688,CIGNA [1000112],CIGNA [100011201],,,68,,34111.4112,7771.48,46412.6656,percent of total billed charges,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,18648.29,13053.803,CIGNA [1000112],CIGNA [100011201],,,68,,12680.8372,6219.204715,25096.964,percent of total billed charges,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,10877.8,7614.46,CIGNA [1000112],CIGNA [100011201],,,68,,7396.904,3627.7463,19285.2488,percent of total billed charges,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,32327.52,22629.264,CIGNA [1000112],CIGNA [100011201],,,68,,21982.7136,7771.48,28507.3952,percent of total billed charges,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,22300.24,15610.168,CIGNA [1000112],CIGNA [100011201],,,68,,15164.1632,6364.97,18701.6456,percent of total billed charges,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,33797.91,23658.537,CIGNA [1000112],CIGNA [100011201],,,68,,22982.5788,7771.48,31366.6456,percent of total billed charges,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,19042.28,13329.596,CIGNA [1000112],CIGNA [100011201],,,68,,12948.7504,6350.60038,42357.8392,percent of total billed charges,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,19035.73,13325.011,CIGNA [1000112],CIGNA [100011201],,,68,,12944.2964,6348.415955,20590.2504,percent of total billed charges,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,34218.62,23953.034,CIGNA [1000112],CIGNA [100011201],,,68,,23268.6616,7771.48,51371.2664,percent of total billed charges,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,53653,37557.1,CIGNA [1000112],CIGNA [100011201],,,68,,36484.04,7771.48,45233.3008,percent of total billed charges,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,70337.4,49236.18,CIGNA [1000112],CIGNA [100011201],,,68,,47829.432,7771.48,94819.3088,percent of total billed charges,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,inpatient,,,93776.03,65643.221,CIGNA [1000112],CIGNA [100011201],,,68,,63767.7004,7771.48,75020.824,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,73575.27,51502.689,CIGNA [1000112],CIGNA [100011201],,,68,,50031.1836,7771.48,96764.6528,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,inpatient,,,54189.56,37932.692,CIGNA [1000112],CIGNA [100011201],,,68,,36848.9008,7771.48,47816.9608,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,45890.81,32123.567,CIGNA [1000112],CIGNA [100011201],,,68,,31205.7508,7771.48,36712.648,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,19580.15,13706.105,CIGNA [1000112],CIGNA [100011201],,,68,,13314.502,6529.980025,62486.0704,percent of total billed charges,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC,830,MS-DRG,,,,,,,inpatient,,,39587.15,27711.005,CIGNA [1000112],CIGNA [100011201],,,68,,26919.262,7771.48,31669.72,percent of total billed charges,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,19450.76,13615.532,CIGNA [1000112],CIGNA [100011201],,,68,,13226.5168,6486.82846,23321.8376,percent of total billed charges,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,17150.01,12005.007,CIGNA [1000112],CIGNA [100011201],,,68,,11662.0068,5642.16,15143.2872,percent of total billed charges,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,11361.65,7953.155,CIGNA [1000112],CIGNA [100011201],,,68,,7725.922,3789.110275,10533.2272,percent of total billed charges,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,9828.38,6879.866,CIGNA [1000112],CIGNA [100011201],,,68,,6683.2984,3277.76473,111997.1016,percent of total billed charges,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,18619.01,13033.307,CIGNA [1000112],CIGNA [100011201],,,68,,12660.9268,6209.439835,43279.8512,percent of total billed charges,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,24808.35,17365.845,CIGNA [1000112],CIGNA [100011201],,,68,,16869.678,7771.48,64630.0016,percent of total billed charges,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,16962.7,11873.89,CIGNA [1000112],CIGNA [100011201],,,68,,11534.636,5657.06045,31771.9256,percent of total billed charges,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,31741.3,22218.91,CIGNA [1000112],CIGNA [100011201],,,68,,21584.084,7771.48,25393.04,percent of total billed charges,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,19222.18,13455.526,CIGNA [1000112],CIGNA [100011201],,,68,,13071.0824,6410.59703,38361.7784,percent of total billed charges,
Radiotherapy,849,MS-DRG,,,,,,,inpatient,,,58144.26,40700.982,CIGNA [1000112],CIGNA [100011201],,,68,,39538.0968,7771.48,54123.1176,percent of total billed charges,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,85769.92,60038.944,CIGNA [1000112],CIGNA [100011201],,,68,,58323.5456,7771.48,101350.396,percent of total billed charges,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,33994.9,23796.43,CIGNA [1000112],CIGNA [100011201],,,68,,23116.532,7771.48,40491.5248,percent of total billed charges,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65980.01,46186.007,CIGNA [1000112],CIGNA [100011201],,,68,,44866.4068,7771.48,91416.9832,percent of total billed charges,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,32658.71,22861.097,CIGNA [1000112],CIGNA [100011201],,,68,,22207.9228,7771.48,44153.2296,percent of total billed charges,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,20565.93,14396.151,CIGNA [1000112],CIGNA [100011201],,,68,,13984.8324,6858.737655,37257.3904,percent of total billed charges,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,17400.21,12180.147,CIGNA [1000112],CIGNA [100011201],,,68,,11832.1428,5802.970035,20261.9736,percent of total billed charges,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,17612.23,12328.561,CIGNA [1000112],CIGNA [100011201],,,68,,11976.3164,5873.678705,18195.0456,percent of total billed charges,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,43267.27,30287.089,CIGNA [1000112],CIGNA [100011201],,,68,,29421.7436,7771.48,34613.816,percent of total billed charges,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,18403.74,12882.618,CIGNA [1000112],CIGNA [100011201],,,68,,12514.5432,6057.47,17927.5608,percent of total billed charges,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,61414.22,42989.954,CIGNA [1000112],CIGNA [100011201],,,68,,41761.6696,7771.48,49131.376,percent of total billed charges,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,15482.04,10837.428,CIGNA [1000112],CIGNA [100011201],,,68,,10527.7872,5163.26034,21277.2,percent of total billed charges,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,13610,9527,CIGNA [1000112],CIGNA [100011201],,,68,,9254.8,4538.935,14579.948,percent of total billed charges,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,148503.39,103952.373,CIGNA [1000112],CIGNA [100011201],,,68,,100982.3052,7771.48,140966.516,percent of total billed charges,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,33194.92,23236.444,CIGNA [1000112],CIGNA [100011201],,,68,,22572.5456,7771.48,39764.0472,percent of total billed charges,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,18792.68,13154.876,CIGNA [1000112],CIGNA [100011201],,,68,,12779.0224,6267.35878,20892.184,percent of total billed charges,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,12279.31,8595.517,CIGNA [1000112],CIGNA [100011201],,,68,,8349.9308,4095.149885,19425.0704,percent of total billed charges,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,25117.86,17582.502,CIGNA [1000112],CIGNA [100011201],,,68,,17080.1448,7771.48,33842.9064,percent of total billed charges,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,22405.38,15683.766,CIGNA [1000112],CIGNA [100011201],,,68,,15235.6584,7472.19423,28562.108,percent of total billed charges,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,13917.07,9741.949,CIGNA [1000112],CIGNA [100011201],,,68,,9463.6076,3961.38,12646.7624,percent of total billed charges,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,48007.28,33605.096,CIGNA [1000112],CIGNA [100011201],,,68,,32644.9504,7771.48,38405.824,percent of total billed charges,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,20565.28,14395.696,CIGNA [1000112],CIGNA [100011201],,,68,,13984.3904,5972.81,17876.9008,percent of total billed charges,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,61408.52,42985.964,CIGNA [1000112],CIGNA [100011201],,,68,,41757.7936,7771.48,80721.644,percent of total billed charges,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,26863.69,18804.583,CIGNA [1000112],CIGNA [100011201],,,68,,18267.3092,7771.48,40872.488,percent of total billed charges,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,27835,19484.5,CIGNA [1000112],CIGNA [100011201],,,68,,18927.8,7771.48,25698.8048,percent of total billed charges,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,30162.14,21113.498,CIGNA [1000112],CIGNA [100011201],,,68,,20510.2552,7771.48,32791.2048,percent of total billed charges,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42212,29548.4,CIGNA [1000112],CIGNA [100011201],,,68,,28704.16,7771.48,35214.7792,percent of total billed charges,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,17347.78,12143.446,CIGNA [1000112],CIGNA [100011201],,,68,,11796.4904,4755.82,13878.224,percent of total billed charges,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,43962.28,30773.596,CIGNA [1000112],CIGNA [100011201],,,68,,29894.3504,7771.48,35169.824,percent of total billed charges,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,17818.34,12472.838,CIGNA [1000112],CIGNA [100011201],,,68,,12116.4712,5723.92,17921.4816,percent of total billed charges,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,31482.85,22037.995,CIGNA [1000112],CIGNA [100011201],,,68,,21408.338,7771.48,36949.3776,percent of total billed charges,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,15673.65,10971.555,CIGNA [1000112],CIGNA [100011201],,,68,,10658.082,5227.162275,20584.1712,percent of total billed charges,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,7247.46,5073.222,CIGNA [1000112],CIGNA [100011201],,,68,,4928.2728,2417.02791,13933.5264,percent of total billed charges,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,28001.68,19601.176,CIGNA [1000112],CIGNA [100011201],,,68,,19041.1424,6731.81,22401.344,percent of total billed charges,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC,939,MS-DRG,,,,,,,inpatient,,,23950.54,16765.378,CIGNA [1000112],CIGNA [100011201],,,68,,16286.3672,7771.48,64313.8832,percent of total billed charges,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,49540.17,34678.119,CIGNA [1000112],CIGNA [100011201],,,68,,33687.3156,7771.48,42783.3832,percent of total billed charges,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC,941,MS-DRG,,,,,,,inpatient,,,17064.75,11945.325,CIGNA [1000112],CIGNA [100011201],,,68,,11604.03,5691.094125,39599.9088,percent of total billed charges,
Rehabilitation With Cc/McC,945,MS-DRG,,,,,,,inpatient,,,45131.85,31592.295,CIGNA [1000112],CIGNA [100011201],,,68,,30689.658,7771.48,36105.48,percent of total billed charges,
Rehabilitation Without Cc/McC,946,MS-DRG,,,,,,,inpatient,,,44615.43,31230.801,CIGNA [1000112],CIGNA [100011201],,,68,,30338.4924,7771.48,35692.344,percent of total billed charges,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,22069.35,15448.545,CIGNA [1000112],CIGNA [100011201],,,68,,15007.158,7360.128225,26061.5304,percent of total billed charges,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,17906.41,12534.487,CIGNA [1000112],CIGNA [100011201],,,68,,12176.3588,5684.12,16099.748,percent of total billed charges,
Aftercare With Cc/McC,949,MS-DRG,,,,,,,inpatient,,,33492.73,23444.911,CIGNA [1000112],CIGNA [100011201],,,68,,22775.0564,7771.48,26794.184,percent of total billed charges,
Aftercare Without Cc/McC,950,MS-DRG,,,,,,,inpatient,,,9898.64,6929.048,CIGNA [1000112],CIGNA [100011201],,,68,,6731.0752,3301.19644,11876.7304,percent of total billed charges,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,4337.06,3035.942,CIGNA [1000112],CIGNA [100011201],,,68,,2949.2008,1446.40951,11487.6616,percent of total billed charges,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,61892.75,43324.925,CIGNA [1000112],CIGNA [100011201],,,68,,42087.07,7771.48,77453.0608,percent of total billed charges,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,12905.91,9034.137,CIGNA [1000112],CIGNA [100011201],,,68,,8776.0188,4304.120985,30400.0528,percent of total billed charges,
Other Multiple Significant Trauma Without Cc/McC,965,MS-DRG,,,,,,,inpatient,,,19234.18,13463.926,CIGNA [1000112],CIGNA [100011201],,,68,,13079.2424,6414.59903,18490.9,percent of total billed charges,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,37958.81,26571.167,CIGNA [1000112],CIGNA [100011201],,,68,,25811.9908,7771.48,60508.304,percent of total billed charges,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,12545.67,8781.969,CIGNA [1000112],CIGNA [100011201],,,68,,8531.0556,4183.980945,29216.6352,percent of total billed charges,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,108861.48,76203.036,CIGNA [1000112],CIGNA [100011201],,,68,,74025.8064,7771.48,96341.1352,percent of total billed charges,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,62893.24,44025.268,CIGNA [1000112],CIGNA [100011201],,,68,,42767.4032,7771.48,50314.592,percent of total billed charges,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,59507.83,41655.481,CIGNA [1000112],CIGNA [100011201],,,68,,40465.3244,7771.48,47606.264,percent of total billed charges,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51559.92,36091.944,CIGNA [1000112],CIGNA [100011201],,,68,,35060.7456,7771.48,70984.792,percent of total billed charges,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,16279.53,11395.671,CIGNA [1000112],CIGNA [100011201],,,68,,11070.0804,5429.223255,34773.024,percent of total billed charges,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,989,MS-DRG,,,,,,,inpatient,,,64497.43,45148.201,CIGNA [1000112],CIGNA [100011201],,,68,,43858.2524,7771.48,51597.944,percent of total billed charges,
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,inpatient,,,7296.22,5107.354,CIGNA [1000112],CIGNA [100011201],,,68,,4961.4296,2433.28937,7947.23,percent of total billed charges,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,49.612,17.7355,1592,percent of total billed charges,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1328.848,399.86,2141,percent of total billed charges,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,162.024,57.921,1592,percent of total billed charges,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,546.988,195.5395,1592,percent of total billed charges,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,434.576,155.354,2141,percent of total billed charges,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,CIGNA [1000112],CIGNA [100011201],,,62.8,,1168.08,291.227805,2141,percent of total billed charges,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.64,29.185,1592,percent of total billed charges,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,579.016,206.989,1592,percent of total billed charges,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,579.016,206.989,1592,percent of total billed charges,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3038.264,399.86,3715.584,percent of total billed charges,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,575.248,205.642,1592,percent of total billed charges,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,575.248,205.642,1592,percent of total billed charges,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,CIGNA [1000112],CIGNA [100011201],,,62.8,,5425.92,399.86,6635.52,percent of total billed charges,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,737.272,263.563,1592,percent of total billed charges,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,33.284,11.8985,1592,percent of total billed charges,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1278.608,399.86,2998,percent of total billed charges,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1256.628,399.86,2998,percent of total billed charges,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1139.82,399.86,2998,percent of total billed charges,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,443.368,158.497,3914,percent of total billed charges,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1326.964,399.86,2141,percent of total billed charges,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1379.716,399.86,2141,percent of total billed charges,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,639.304,228.541,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,668.82,239.0925,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1776.612,399.86,2477.315575,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,755.484,270.0735,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,755.484,270.0735,1592,percent of total billed charges,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,CIGNA [1000112],CIGNA [100011201],,,62.8,,1199.48,399.86,1592,percent of total billed charges,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,217.916,62.19,1592,percent of total billed charges,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,217.916,66.75974,1592,percent of total billed charges,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,133.136,47.594,1592,percent of total billed charges,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,270.668,96.7595,1592,percent of total billed charges,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,87.292,31.2055,1592,percent of total billed charges,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,99.852,35.6955,1592,percent of total billed charges,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1201.992,399.86,1592,percent of total billed charges,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1379.716,399.86,2141,percent of total billed charges,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.852,113.876282,1592,percent of total billed charges,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,864.756,156.65,1592,percent of total billed charges,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,317.14,113.3725,1592,percent of total billed charges,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,317.14,113.3725,1592,percent of total billed charges,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,279.46,99.9025,1592,percent of total billed charges,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,322.164,115.1685,1592,percent of total billed charges,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,406.944,145.476,1592,percent of total billed charges,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,266.9,95.4125,1592,percent of total billed charges,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,206.612,73.8605,1592,percent of total billed charges,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,CIGNA [1000112],CIGNA [100011201],,,62.8,,251.2,89.8,1592,percent of total billed charges,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,300.812,107.5355,1592,percent of total billed charges,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,397.524,142.1085,1592,percent of total billed charges,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,489.212,174.8855,1592,percent of total billed charges,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,348.54,124.5975,1592,percent of total billed charges,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,281.344,100.576,1592,percent of total billed charges,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,864.756,309.1365,1592,percent of total billed charges,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,508.052,181.6205,1592,percent of total billed charges,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,559.548,200.0295,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,317.14,113.3725,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,430.18,153.7825,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,430.18,153.7825,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.572,145.7005,1592,percent of total billed charges,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2828.512,399.86,3459.072,percent of total billed charges,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,398.152,142.333,1592,percent of total billed charges,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,397.524,142.1085,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,391.244,139.8635,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,393.756,140.7615,1592,percent of total billed charges,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,663.168,237.072,2141,percent of total billed charges,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3289.464,399.86,4022.784,percent of total billed charges,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,559.548,200.0295,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,374.288,133.802,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,416.364,148.8435,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,409.456,146.374,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,470.372,168.1505,1592,percent of total billed charges,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,891.132,318.5655,1592,percent of total billed charges,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,710.896,254.134,1592,percent of total billed charges,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1149.868,399.86,1592,percent of total billed charges,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,CIGNA [1000112],CIGNA [100011201],,,62.8,,684.52,244.705,1592,percent of total billed charges,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,CIGNA [1000112],CIGNA [100011201],,,62.8,,157,56.125,1592,percent of total billed charges,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1105.908,395.3445,1592,percent of total billed charges,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.58,165.0075,1592,percent of total billed charges,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,191.54,68.4725,1592,percent of total billed charges,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,719.06,257.0525,1592,percent of total billed charges,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,454.044,162.3135,1592,percent of total billed charges,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,362.984,129.761,1592,percent of total billed charges,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1105.908,395.3445,1592,percent of total billed charges,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,466.604,166.8035,1592,percent of total billed charges,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,290.136,103.719,1592,percent of total billed charges,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2828.512,399.86,3459.072,percent of total billed charges,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1149.868,108.7,1592,percent of total billed charges,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,2150.9,399.86,4341.777195,percent of total billed charges,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4746.424,399.86,5804.544,percent of total billed charges,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5988.608,399.86,7323.648,percent of total billed charges,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,3661.868,399.86,4478.208,percent of total billed charges,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4746.424,399.86,5804.544,percent of total billed charges,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,3661.868,399.86,5481.863562,percent of total billed charges,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5988.608,399.86,7323.648,percent of total billed charges,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4746.424,399.86,5804.544,percent of total billed charges,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,246.804,88.2285,1592,percent of total billed charges,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,509.936,182.294,1592,percent of total billed charges,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,509.936,182.294,1592,percent of total billed charges,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,530.66,189.7025,1592,percent of total billed charges,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,CIGNA [1000112],CIGNA [100011201],,,62.8,,420.76,150.415,2998,percent of total billed charges,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1107.164,395.7935,1592,percent of total billed charges,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1028.036,367.5065,2141,percent of total billed charges,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,CIGNA [1000112],CIGNA [100011201],,,62.8,,37.68,13.47,1592,percent of total billed charges,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,2711.076,399.86,3315.456,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2510.744,399.86,3070.464,percent of total billed charges,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2054.188,399.86,2998,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1467.008,399.86,1794.048,percent of total billed charges,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,CIGNA [1000112],CIGNA [100011201],,,62.8,,3215.36,399.86,3932.16,percent of total billed charges,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1401.696,399.86,1714.176,percent of total billed charges,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,108.7,2998,percent of total billed charges,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.64,197.56,1592,percent of total billed charges,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1328.848,108.7,2141,percent of total billed charges,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,52.752,18.858,1592,percent of total billed charges,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,737.9,108.7,2141,percent of total billed charges,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,172.072,61.513,1592,percent of total billed charges,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1328.848,108.7,2141,percent of total billed charges,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,8820.26,399.86,14403.82399,percent of total billed charges,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,2415.916,399.86,2954.496,percent of total billed charges,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,911.228,235.074116,1592,percent of total billed charges,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3276.904,399.86,4007.424,percent of total billed charges,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3638.004,399.86,4449.024,percent of total billed charges,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,516.844,184.7635,1592,percent of total billed charges,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,567.084,202.7235,1592,percent of total billed charges,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,413.224,147.721,1592,percent of total billed charges,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,448.392,160.293,1592,percent of total billed charges,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,448.392,160.293,1592,percent of total billed charges,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,589.064,210.581,1592,percent of total billed charges,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,472.884,169.0485,1592,percent of total billed charges,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,472.884,169.0485,1592,percent of total billed charges,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1158.032,399.86,2141,percent of total billed charges,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,413.224,147.721,1592,percent of total billed charges,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,413.224,147.721,1592,percent of total billed charges,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,492.352,176.008,1592,percent of total billed charges,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,10345.044,399.86,20110.10933,percent of total billed charges,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,3011.888,399.86,3683.328,percent of total billed charges,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1064.46,380.5275,1592,percent of total billed charges,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1571.256,399.86,2477.315575,percent of total billed charges,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,699.592,235.074116,1592,percent of total billed charges,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.58,165.0075,1592,percent of total billed charges,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2263.312,399.86,2998,percent of total billed charges,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3276.904,399.86,4341.777195,percent of total billed charges,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.776,399.86,2998,percent of total billed charges,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3276.904,399.86,4007.424,percent of total billed charges,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,768.672,274.788,1592,percent of total billed charges,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3129.324,399.86,3826.944,percent of total billed charges,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,13577.988,399.86,16604.928,percent of total billed charges,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3276.904,399.86,4007.424,percent of total billed charges,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,CIGNA [1000112],CIGNA [100011201],,,62.8,,1042.48,235.074116,1592,percent of total billed charges,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1609.564,399.86,2455.793921,percent of total billed charges,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1609.564,399.86,2998,percent of total billed charges,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3129.324,399.86,3826.944,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3129.324,399.86,3826.944,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3129.324,399.86,3826.944,percent of total billed charges,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2841.6,percent of total billed charges,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2841.6,percent of total billed charges,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,997.892,235.074116,1592,percent of total billed charges,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2197.372,399.86,2998,percent of total billed charges,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,566.456,202.499,1592,percent of total billed charges,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1788.544,399.86,2455.793921,percent of total billed charges,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.388,150.6395,1592,percent of total billed charges,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1284.26,399.86,2998,percent of total billed charges,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,449.02,160.5175,1592,percent of total billed charges,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,4812.364,399.86,5885.184,percent of total billed charges,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,908.088,324.627,1592,percent of total billed charges,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,523.752,187.233,1592,percent of total billed charges,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2300.364,292.65,2813.184,percent of total billed charges,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,416.992,149.068,1592,percent of total billed charges,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,560.804,200.4785,1592,percent of total billed charges,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,308.348,110.2295,1592,percent of total billed charges,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,320.908,114.7195,1592,percent of total billed charges,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,284.484,101.6985,1592,percent of total billed charges,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,1592,percent of total billed charges,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,1592,percent of total billed charges,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,138.788,49.6145,1592,percent of total billed charges,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,136.904,48.941,1592,percent of total billed charges,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,254.34,90.9225,1592,percent of total billed charges,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,76.616,27.389,1592,percent of total billed charges,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,76.616,27.389,1592,percent of total billed charges,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,438.972,156.9255,1592,percent of total billed charges,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,347.912,124.373,1592,percent of total billed charges,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,1592,percent of total billed charges,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,217.916,77.9015,1592,percent of total billed charges,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,217.916,77.9015,1592,percent of total billed charges,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,181.492,64.8805,1592,percent of total billed charges,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,181.492,64.8805,1592,percent of total billed charges,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,305.208,109.107,1592,percent of total billed charges,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,CIGNA [1000112],CIGNA [100011201],,,62.8,,320.28,114.495,1592,percent of total billed charges,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,341.632,122.128,1592,percent of total billed charges,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,341.632,122.128,1592,percent of total billed charges,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,341.632,122.128,1592,percent of total billed charges,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,386.22,138.0675,1592,percent of total billed charges,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,232.988,83.2895,1592,percent of total billed charges,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1978.828,399.86,2998,percent of total billed charges,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,CIGNA [1000112],CIGNA [100011201],,,62.8,,1978.2,399.86,2998,percent of total billed charges,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,2471.18,399.86,3022.08,percent of total billed charges,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2054.188,399.86,2998,percent of total billed charges,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2885.032,399.86,3528.192,percent of total billed charges,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5254.476,399.86,6425.856,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1225.228,399.86,2447.133941,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1225.228,399.86,2447.133941,percent of total billed charges,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1225.228,399.86,2447.133941,percent of total billed charges,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1225.228,399.86,2447.133941,percent of total billed charges,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1422.42,399.86,2141,percent of total billed charges,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2636.344,399.86,3224.064,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1176.872,399.86,2141,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1027.408,367.282,2141,percent of total billed charges,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1027.408,367.282,2141,percent of total billed charges,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1818.688,399.86,2998,percent of total billed charges,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1181.896,399.86,2447.133941,percent of total billed charges,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1422.42,399.86,1739.52,percent of total billed charges,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,892.388,319.0145,2141,percent of total billed charges,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,892.388,319.0145,2141,percent of total billed charges,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,3477.236,399.86,4252.416,percent of total billed charges,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,3477.236,399.86,4252.416,percent of total billed charges,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,23089.676,399.86,28237.056,percent of total billed charges,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,13474.368,399.86,16478.208,percent of total billed charges,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,13474.368,399.86,16478.208,percent of total billed charges,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2530.212,399.86,4870.452937,percent of total billed charges,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,13474.368,399.86,16478.208,percent of total billed charges,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,30758.812,399.86,37615.872,percent of total billed charges,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2828.512,399.86,3459.072,percent of total billed charges,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1705.648,399.86,2998,percent of total billed charges,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,4754.588,399.86,6364,percent of total billed charges,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2288.432,399.86,4870.452937,percent of total billed charges,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,11169.608,399.86,13659.648,percent of total billed charges,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,12341.456,399.86,16316.30039,percent of total billed charges,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,14181.496,399.86,29773.2518,percent of total billed charges,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,42387.488,399.86,51836.928,percent of total billed charges,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,40818.744,399.86,50269.54813,percent of total billed charges,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,13474.368,399.86,16478.208,percent of total billed charges,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,5669.584,399.86,6933.504,percent of total billed charges,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,54249.152,399.86,66342.912,percent of total billed charges,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,39567.768,399.86,48388.608,percent of total billed charges,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,41292.256,399.86,50497.536,percent of total billed charges,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,41292.256,399.86,50497.536,percent of total billed charges,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,17413.184,399.86,21295.104,percent of total billed charges,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,17413.184,399.86,21295.104,percent of total billed charges,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,22573.824,percent of total billed charges,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,22573.824,percent of total billed charges,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,24913.5068,percent of total billed charges,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,17413.184,399.86,23502.2528,percent of total billed charges,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,24913.5068,percent of total billed charges,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,24913.5068,percent of total billed charges,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,4365.228,399.86,5338.368,percent of total billed charges,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,CIGNA [1000112],CIGNA [100011201],,,62.8,,3749.16,399.86,4584.96,percent of total billed charges,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,CIGNA [1000112],CIGNA [100011201],,,62.8,,2775.76,399.86,3746.392,percent of total billed charges,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1035.572,370.2005,2998,percent of total billed charges,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.96,399.86,3237.832,percent of total billed charges,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2633.832,399.86,3220.992,percent of total billed charges,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,CIGNA [1000112],CIGNA [100011201],,,62.8,,1130.4,399.86,2998,percent of total billed charges,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1578.164,399.86,6913,percent of total billed charges,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,87.292,31.2055,6913,percent of total billed charges,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2580.452,399.86,3155.712,percent of total billed charges,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2630.064,399.86,3549.7488,percent of total billed charges,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2630.064,399.86,3549.7488,percent of total billed charges,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2580.452,399.86,3155.712,percent of total billed charges,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2630.064,293.5896,3216.384,percent of total billed charges,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,CIGNA [1000112],CIGNA [100011201],,,62.8,,1111.56,397.365,2141,percent of total billed charges,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,CIGNA [1000112],CIGNA [100011201],,,62.8,,1111.56,397.365,2141,percent of total billed charges,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.456,34.124,2998,percent of total billed charges,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,149.464,53.431,2998,percent of total billed charges,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,104.876,37.4915,2998,percent of total billed charges,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,211.636,75.6565,2998,percent of total billed charges,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,280.716,100.3515,2998,percent of total billed charges,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,136.904,48.941,2998,percent of total billed charges,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,215.404,77.0035,1592,percent of total billed charges,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,486.7,173.9875,2141,percent of total billed charges,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,162.024,57.921,1592,percent of total billed charges,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,339.748,121.4545,1592,percent of total billed charges,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,485.444,173.5385,1592,percent of total billed charges,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.852,204.0705,1592,percent of total billed charges,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,5231.868,399.86,6398.208,percent of total billed charges,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,452.788,161.8645,1592,percent of total billed charges,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1043.736,373.119,1592,percent of total billed charges,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.384,140.986,1592,percent of total billed charges,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,CIGNA [1000112],CIGNA [100011201],,,62.8,,213.52,76.33,1592,percent of total billed charges,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1638.452,399.86,2003.712,percent of total billed charges,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,452.788,161.8645,1592,percent of total billed charges,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,CIGNA [1000112],CIGNA [100011201],,,62.8,,646.84,231.235,1592,percent of total billed charges,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,356.704,127.516,1592,percent of total billed charges,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,970.26,346.8525,1592,percent of total billed charges,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,68.452,24.4705,1592,percent of total billed charges,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,6085.948,399.86,7442.688,percent of total billed charges,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,6085.948,399.86,7442.688,percent of total billed charges,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,5740.548,399.86,8396.844904,percent of total billed charges,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,9951.916,399.86,12170.496,percent of total billed charges,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,5740.548,399.86,7020.288,percent of total billed charges,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,9951.916,399.86,12170.496,percent of total billed charges,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,323.42,115.6175,1592,percent of total billed charges,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,384.336,137.394,1592,percent of total billed charges,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,695.196,248.5215,1592,percent of total billed charges,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,776.208,277.482,1592,percent of total billed charges,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,905.576,323.729,1592,percent of total billed charges,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,162.024,57.921,1592,percent of total billed charges,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,CIGNA [1000112],CIGNA [100011201],,,62.8,,5922.04,399.86,7242.24,percent of total billed charges,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,CIGNA [1000112],CIGNA [100011201],,,62.8,,5922.04,399.86,7242.24,percent of total billed charges,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,CIGNA [1000112],CIGNA [100011201],,,62.8,,5922.04,399.86,8396.844904,percent of total billed charges,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,CIGNA [1000112],CIGNA [100011201],,,62.8,,5922.04,399.86,7242.24,percent of total billed charges,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,CIGNA [1000112],CIGNA [100011201],,,,,,5.388,416.02,other,Venipuncture and Blood Draw No Pay
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,579.644,207.2135,1592,percent of total billed charges,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.852,156.65,1592,percent of total billed charges,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.852,204.0705,1592,percent of total billed charges,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,240.524,85.9835,1592,percent of total billed charges,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,6623.08,percent of total billed charges,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1128.516,399.86,1592,percent of total billed charges,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1128.516,399.86,1592,percent of total billed charges,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,1592,percent of total billed charges,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,258.736,92.494,1592,percent of total billed charges,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,485.444,173.5385,1592,percent of total billed charges,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,839.636,300.1565,2081.64,percent of total billed charges,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,3089.132,399.86,3777.792,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,6012.672,percent of total billed charges,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,6012.672,percent of total billed charges,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,4916.612,399.86,6012.672,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2953.728,percent of total billed charges,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,2415.288,399.86,2953.728,percent of total billed charges,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,892.388,319.0145,2141,percent of total billed charges,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,892.388,319.0145,2141,percent of total billed charges,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2998,percent of total billed charges,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,CIGNA [1000112],CIGNA [100011201],,,,,,35.92,1592,other,Venipuncture and Blood Draw No Pay
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,CIGNA [1000112],CIGNA [100011201],,,,,,28.0625,1592,other,Venipuncture and Blood Draw No Pay
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,506.168,180.947,1592,percent of total billed charges,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,254.968,91.147,1592,percent of total billed charges,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,186.516,66.6765,1592,percent of total billed charges,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,194.052,69.3705,1592,percent of total billed charges,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6720.856,399.86,9071.0152,percent of total billed charges,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,356.704,127.516,1592,percent of total billed charges,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,356.704,127.516,1592,percent of total billed charges,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,CIGNA [1000112],CIGNA [100011201],,,62.8,,2587.36,399.86,5756,percent of total billed charges,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,8185.98,399.86,18955.84,percent of total billed charges,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,26793.51305,percent of total billed charges,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,517.472,184.988,4800.911611,percent of total billed charges,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,776.208,277.482,8164.18419,percent of total billed charges,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,6788.57,percent of total billed charges,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,CIGNA [1000112],CIGNA [100011201],,,62.8,,8810.84,399.86,10775.04,percent of total billed charges,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6046.384,399.86,7394.304,percent of total billed charges,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6278.744,399.86,7678.464,percent of total billed charges,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,384.964,137.6185,1592,percent of total billed charges,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,5542.1,399.86,6777.6,percent of total billed charges,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2034.092,399.86,4870.452937,percent of total billed charges,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,4536.672,399.86,5548.032,percent of total billed charges,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,4536.672,399.86,5548.032,percent of total billed charges,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,347.284,124.1485,2998,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,10044.232,399.86,12283.392,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,10422.916,399.86,18955.84,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,9933.704,399.86,12148.224,percent of total billed charges,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,10183.648,399.86,12453.888,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,10424.172,399.86,12748.032,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,CIGNA [1000112],CIGNA [100011201],,,62.8,,21395.96,399.86,26793.51305,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,20459.612,399.86,25020.672,percent of total billed charges,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,37055.14,399.86,45315.84,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,10047.372,399.86,16809.6787,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,21895.848,399.86,26793.51305,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,CIGNA [1000112],CIGNA [100011201],,,62.8,,21395.96,399.86,26793.51305,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,36515.688,399.86,44656.128,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,10080.656,399.86,12327.936,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,21085.728,399.86,25786.368,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,10080.656,399.86,12327.936,percent of total billed charges,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,9933.704,399.86,12148.224,percent of total billed charges,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2498.184,399.86,4532,percent of total billed charges,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2498.184,399.86,4532,percent of total billed charges,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,26793.51305,percent of total billed charges,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2915.804,399.86,3565.824,percent of total billed charges,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,239.268,85.5345,1592,percent of total billed charges,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1239.044,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1239.044,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1238.416,399.86,2477.315575,percent of total billed charges,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1238.416,399.86,2477.315575,percent of total billed charges,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2922.084,399.86,4341.777195,percent of total billed charges,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2922.084,399.86,4341.777195,percent of total billed charges,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1239.044,399.86,2998,percent of total billed charges,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,CIGNA [1000112],CIGNA [100011201],,,62.8,,314,112.25,1592,percent of total billed charges,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,CIGNA [1000112],CIGNA [100011201],,,62.8,,339.12,121.23,1592,percent of total billed charges,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1631.544,399.86,2477.315575,percent of total billed charges,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1028.036,367.5065,2141,percent of total billed charges,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,266.272,95.188,1592,percent of total billed charges,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,334.724,119.6585,1592,percent of total billed charges,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,430.18,153.7825,1592,percent of total billed charges,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,204.1,72.9625,1592,percent of total billed charges,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,204.1,72.9625,1592,percent of total billed charges,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,363.612,129.9855,1592,percent of total billed charges,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,311.488,111.352,1592,percent of total billed charges,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.012,197.3355,1592,percent of total billed charges,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.012,197.3355,1592,percent of total billed charges,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1050.644,375.5885,2998,percent of total billed charges,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1712.556,399.86,4005.9,percent of total billed charges,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,4034.9,399.86,4934.4,percent of total billed charges,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,2333.648,399.86,2998,percent of total billed charges,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,610.416,218.214,1592,percent of total billed charges,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,8356.796,399.86,10219.776,percent of total billed charges,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5254.476,399.86,6425.856,percent of total billed charges,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5254.476,399.86,6425.856,percent of total billed charges,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,8356.796,399.86,15728.70471,percent of total billed charges,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,CIGNA [1000112],CIGNA [100011201],,,62.8,,1092.72,390.63,2998,percent of total billed charges,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,5378.192,399.86,6577.152,percent of total billed charges,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,5378.192,399.86,6577.152,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,580.9,207.6625,2998,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.78,367.0575,2998,percent of total billed charges,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.78,367.0575,2998,percent of total billed charges,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5254.476,399.86,6425.856,percent of total billed charges,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,CIGNA [1000112],CIGNA [100011201],,,62.8,,1802.36,399.86,2998,percent of total billed charges,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1662.316,399.86,2998,percent of total billed charges,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,5001.392,399.86,6116.352,percent of total billed charges,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2682.188,399.86,3280.128,percent of total billed charges,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,308.348,110.2295,1592,percent of total billed charges,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2682.188,399.86,3280.128,percent of total billed charges,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2682.188,399.86,3280.128,percent of total billed charges,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1032.432,369.078,2998,percent of total billed charges,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1032.432,369.078,2998,percent of total billed charges,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1062.576,379.854,2998,percent of total billed charges,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1062.576,379.854,2998,percent of total billed charges,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1643.476,399.86,2998,percent of total billed charges,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1643.476,399.86,2998,percent of total billed charges,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1336.384,399.86,2998,percent of total billed charges,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,380.568,136.047,1592,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,CIGNA [1000112],CIGNA [100011201],,,62.8,,31.58212,1.160665,416.02,percent of total billed charges,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,CIGNA [1000112],CIGNA [100011201],,,62.8,,3.24676,1.160665,416.02,percent of total billed charges,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,4179.83,percent of total billed charges,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,950.164,339.6685,2141,percent of total billed charges,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,455.928,162.987,2141,percent of total billed charges,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,334.724,119.6585,1592,percent of total billed charges,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,950.164,334.48,2141,percent of total billed charges,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,3455.256,399.86,4225.536,percent of total billed charges,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,7286.684,399.86,8911.104,percent of total billed charges,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,8356.796,399.86,10219.776,percent of total billed charges,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,234.872,83.963,1592,percent of total billed charges,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,334.724,119.6585,1592,percent of total billed charges,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,7286.684,399.86,8911.104,percent of total billed charges,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,7286.684,399.86,8911.104,percent of total billed charges,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,438.972,156.9255,1592,percent of total billed charges,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,438.972,156.9255,1592,percent of total billed charges,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1519.132,179.53,2998,percent of total billed charges,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1519.132,179.53,2998,percent of total billed charges,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,913.74,235.074116,1592,percent of total billed charges,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,612.928,219.112,1592,percent of total billed charges,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.012,197.3355,1592,percent of total billed charges,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,244.292,87.3305,1592,percent of total billed charges,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,245.548,87.7795,1592,percent of total billed charges,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,1592,percent of total billed charges,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,286.368,102.372,1592,percent of total billed charges,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,298.3,106.6375,1592,percent of total billed charges,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,133.136,47.594,1592,percent of total billed charges,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5078.008,399.86,6210.048,percent of total billed charges,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,4144.172,399.86,5068.032,percent of total billed charges,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,371.148,120.28264,1592,percent of total billed charges,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,520.612,186.1105,1592,percent of total billed charges,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3148.164,399.86,4777.053449,percent of total billed charges,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,685.776,235.074116,1592,percent of total billed charges,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,CIGNA [1000112],CIGNA [100011201],,,62.8,,4333.2,399.86,5299.2,percent of total billed charges,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,CIGNA [1000112],CIGNA [100011201],,,62.8,,307.72,110.005,416.02,percent of total billed charges,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1922.936,399.86,4777.053449,percent of total billed charges,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,4506.528,399.86,5511.168,percent of total billed charges,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,950.792,339.893,2141,percent of total billed charges,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,3789.98,399.86,11413.04,percent of total billed charges,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1183.78,399.86,2141,percent of total billed charges,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,334.724,119.6585,5756,percent of total billed charges,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1028.036,367.5065,2141,percent of total billed charges,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,2141,percent of total billed charges,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,2141,percent of total billed charges,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,2141,percent of total billed charges,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,788.768,281.972,2141,percent of total billed charges,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,788.768,281.972,2141,percent of total billed charges,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,2141,percent of total billed charges,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,823.936,294.544,1592,percent of total billed charges,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,3958.912,399.86,6224.0876,percent of total billed charges,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,788.768,281.972,1592,percent of total billed charges,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,695.196,248.5215,1592,percent of total billed charges,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1624.008,399.86,2141,percent of total billed charges,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,515.588,155.844464,1592,percent of total billed charges,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,559.548,200.0295,1592,percent of total billed charges,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.152,323.2601,1592,percent of total billed charges,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,550.756,196.8865,1592,percent of total billed charges,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,867.896,310.259,2141,percent of total billed charges,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,CIGNA [1000112],CIGNA [100011201],,,62.8,,3824.52,399.86,4677.12,percent of total billed charges,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.152,366.833,2141,percent of total billed charges,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,518.1,185.2125,1592,percent of total billed charges,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,CIGNA [1000112],CIGNA [100011201],,,62.8,,144.44,51.635,1592,percent of total billed charges,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,261.248,93.392,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,138.788,49.6145,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,140.672,50.288,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,1592,percent of total billed charges,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,33.912,12.123,1592,percent of total billed charges,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1359.62,399.86,2141,percent of total billed charges,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,431.436,154.2315,1592,percent of total billed charges,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,431.436,154.2315,1592,percent of total billed charges,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,128.74,46.0225,1592,percent of total billed charges,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,191.54,66.75974,1592,percent of total billed charges,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,60.8395,416.02,fee schedule,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,456.96,fee schedule,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.208,416.02,fee schedule,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,66.2275,416.02,fee schedule,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,56.574,416.02,fee schedule,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,73.636,416.02,fee schedule,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,58.819,416.02,fee schedule,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,549.888,fee schedule,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,267.439885,1987.584,case rate,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.084,416.02,fee schedule,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,58.819,416.02,fee schedule,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,120.5565,646.6965,fee schedule,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,CIGNA [1000112],CIGNA [100011201],,575,,,575,89.81,821.76,case rate,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,CIGNA [1000112],CIGNA [100011201],,575,,,575,124.33,1023.744,case rate,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,153.75,1240.32,case rate,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,575,case rate,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,173.763,667.43,case rate,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1243.392,case rate,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,921.6,case rate,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1014.528,case rate,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,889.344,case rate,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,575,case rate,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,194.55,1138.176,case rate,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1347.84,case rate,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1021.44,case rate,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,888.576,case rate,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,3902.208,case rate,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,CIGNA [1000112],CIGNA [100011201],,836,,,836,365.99,2081.28,case rate,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,379.854,1299.456,case rate,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,267.439885,1750.272,case rate,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,374.62,1750.272,case rate,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1750.272,case rate,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,267.439885,1675.776,case rate,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,1896.192,case rate,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1946.112,case rate,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,CIGNA [1000112],CIGNA [100011201],,836,,,836,188.66,1605.12,case rate,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,CIGNA [1000112],CIGNA [100011201],,836,,,836,268.7,4035.84,case rate,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,307.14,2049.024,case rate,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,48.043,416.02,fee schedule,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.084,416.02,fee schedule,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,55.0025,416.02,fee schedule,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,431.616,fee schedule,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,56.125,416.02,fee schedule,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,1065.984,case rate,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,195.34,1247.232,case rate,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1522.176,case rate,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,59.268,575,case rate,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1222.656,case rate,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,1519.872,case rate,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2402.304,case rate,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,347.3015,1288.93,case rate,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1817.856,case rate,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1817.856,case rate,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1817.856,case rate,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,56.3495,416.02,fee schedule,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,66.452,416.02,fee schedule,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,67.35,416.02,fee schedule,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,67.35,416.02,fee schedule,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,56.574,416.02,fee schedule,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,63.5335,416.02,fee schedule,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,68.697,416.02,fee schedule,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.4325,416.02,fee schedule,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,581.376,fee schedule,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,581.376,fee schedule,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,52.7575,416.02,fee schedule,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,72.5135,416.02,fee schedule,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,462.336,fee schedule,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,92.2695,416.02,fee schedule,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,1043.712,case rate,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,CIGNA [1000112],CIGNA [100011201],,575,,,575,196.52,1195.008,case rate,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1719.552,case rate,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,698.112,case rate,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,196.52,796.416,case rate,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1704.192,case rate,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,575,case rate,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,195.73,1095.936,case rate,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1057.536,case rate,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,CIGNA [1000112],CIGNA [100011201],,836,,,836,185.92,1624.32,case rate,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,CIGNA [1000112],CIGNA [100011201],,836,,,836,270.27,2337.024,case rate,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,185.92,1706.496,case rate,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,CIGNA [1000112],CIGNA [100011201],,836,,,836,266.73,2183.424,case rate,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,185.92,2035.968,case rate,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,CIGNA [1000112],CIGNA [100011201],,836,,,836,265.17,2031.36,case rate,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,307.53,2399.232,case rate,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,CIGNA [1000112],CIGNA [100011201],,836,,,836,307.93,2175.744,case rate,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,305.58,2443.008,case rate,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,64.4315,416.02,fee schedule,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,974.592,case rate,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,1050.624,case rate,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,195.33,1198.848,case rate,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1460.736,case rate,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,1721.088,case rate,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,CIGNA [1000112],CIGNA [100011201],,836,,,836,372.27,2188.8,case rate,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2114.304,case rate,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2233.344,case rate,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2233.344,case rate,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2233.344,case rate,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,CIGNA [1000112],CIGNA [100011201],,2051.3855,,,2051.3855,331.811,2051.3855,fee schedule,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,CIGNA [1000112],CIGNA [100011201],,2051.3855,,,2051.3855,399.86,2051.3855,fee schedule,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,CIGNA [1000112],CIGNA [100011201],,2051.3855,,,2051.3855,395.12,2051.3855,fee schedule,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,CIGNA [1000112],CIGNA [100011201],,2051.3855,,,2051.3855,399.86,2051.3855,fee schedule,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,CIGNA [1000112],CIGNA [100011201],,4977.9345,,,4977.9345,399.86,4977.9345,fee schedule,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,CIGNA [1000112],CIGNA [100011201],,4977.9345,,,4977.9345,399.86,4977.9345,fee schedule,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,38.165,416.02,fee schedule,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,68.697,416.02,fee schedule,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,57.472,416.02,fee schedule,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,31.2055,416.02,fee schedule,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,379.405,1297.92,fee schedule,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,39.961,416.02,fee schedule,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,38.3895,416.02,fee schedule,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,28.9605,416.02,fee schedule,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,298.8095,1022.208,fee schedule,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,50.5125,416.02,fee schedule,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,42.655,416.02,fee schedule,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1322.496,fee schedule,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,68.697,416.02,fee schedule,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.982,416.02,fee schedule,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,28.9605,416.02,fee schedule,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,736.512,case rate,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,193.37,1065.984,case rate,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1506.048,case rate,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1032.96,case rate,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,2217.984,case rate,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,371.09,2254.848,case rate,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2414.592,case rate,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,204.76,2333.952,case rate,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,340.49,2414.592,case rate,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2350.08,case rate,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,49.839,416.02,fee schedule,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,49.839,416.02,fee schedule,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.4325,416.02,fee schedule,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.4325,416.02,fee schedule,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,581.376,fee schedule,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1241.088,fee schedule,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,47.8185,416.02,fee schedule,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,47.8185,416.02,fee schedule,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.084,416.02,fee schedule,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,58.37,416.02,fee schedule,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,382.548,1308.672,fee schedule,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,44.6755,416.02,fee schedule,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,51.8595,416.02,fee schedule,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,30.7565,416.02,fee schedule,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,29.185,416.02,fee schedule,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1020.2995,fee schedule,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,35.471,416.02,fee schedule,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,36.818,416.02,fee schedule,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.533,416.02,fee schedule,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,43.104,416.02,fee schedule,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,743.424,case rate,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,196.51,758.016,case rate,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1461.504,case rate,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,903.168,case rate,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,2178.048,case rate,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,372.66,1840.128,case rate,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2350.08,case rate,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,205.15,2310.144,case rate,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,345.98,2317.824,case rate,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2379.264,case rate,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2290.176,case rate,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2290.176,case rate,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2290.176,case rate,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.084,416.02,fee schedule,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,92.045,416.02,fee schedule,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,1112.832,case rate,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,CIGNA [1000112],CIGNA [100011201],,575,,,575,194.55,1218.048,case rate,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1580.544,case rate,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,329.339098,1982.208,case rate,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1040.64,case rate,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,142.38,1050.624,case rate,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,204.61123,1513.728,case rate,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,204.61123,1629.696,case rate,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,1810.176,case rate,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,3902.208,case rate,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2072.064,case rate,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1878.528,case rate,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1878.528,case rate,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1878.528,case rate,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,76.026473,753.408,fee schedule,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,128.66,671.232,fee schedule,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,726.596,259.7465,888.576,percent of total billed charges,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,200.53123,703.488,fee schedule,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,194.1925,664.32,fee schedule,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,128.66,2264.832,fee schedule,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,183.14,907.776,fee schedule,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,200.53123,822.528,fee schedule,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,200.53123,1350.144,fee schedule,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,839.008,145.12362,1026.048,percent of total billed charges,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,181.492,64.8805,416.02,percent of total billed charges,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,651.864,145.12362,797.184,percent of total billed charges,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,547.616,195.08,669.696,percent of total billed charges,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1829.364,260.23,2237.184,percent of total billed charges,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,396.268,141.6595,484.608,percent of total billed charges,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1546.136,399.86,1890.816,percent of total billed charges,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,134.4755,499.422,fee schedule,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,200.53123,1595.904,fee schedule,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1020.2995,fee schedule,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,399.86,2172.672,fee schedule,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1020.2995,fee schedule,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,171.069,646.6965,fee schedule,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,171.069,646.6965,fee schedule,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,CIGNA [1000112],CIGNA [100011201],,1393.3385,,,1393.3385,121.679,1393.3385,fee schedule,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,CIGNA [1000112],CIGNA [100011201],,5136.771,,,5136.771,399.86,5136.771,fee schedule,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,237.819698,1301.76,fee schedule,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,CIGNA [1000112],CIGNA [100011201],,,62.8,,797.56,285.115,975.36,percent of total billed charges,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,88.902,1706.496,case rate,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,248.688,88.902,1706.496,percent of total billed charges,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,102.5965,2030.592,case rate,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,286.996,102.5965,2030.592,percent of total billed charges,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,9.2045,836,case rate,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,25.748,9.2045,836,percent of total billed charges,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,19.0825,575,case rate,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,53.38,19.0825,575,percent of total billed charges,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,58.819,669.696,case rate,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,164.536,58.819,669.696,percent of total billed charges,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,CIGNA [1000112],CIGNA [100011201],,575,,,575,58.819,780.288,case rate,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,164.536,58.819,780.288,percent of total billed charges,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,CIGNA [1000112],CIGNA [100011201],,575,,,575,57.921,824.064,case rate,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,162.024,57.921,824.064,percent of total billed charges,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1793.568,399.86,2536.61118,percent of total billed charges,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1321.728,case rate,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2221.864,399.86,2717.184,percent of total billed charges,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,92.2695,416.02,fee schedule,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,CIGNA [1000112],CIGNA [100011201],,4120.349,,,4120.349,399.86,4120.349,fee schedule,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,CIGNA [1000112],CIGNA [100011201],,4120.349,,,4120.349,399.86,4120.349,fee schedule,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,CIGNA [1000112],CIGNA [100011201],,4120.349,,,4120.349,399.86,4120.349,fee schedule,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,CIGNA [1000112],CIGNA [100011201],,1602.0655,,,1602.0655,399.86,3400.704,fee schedule,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,CIGNA [1000112],CIGNA [100011201],,1602.0655,,,1602.0655,367.731,1602.0655,fee schedule,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1592.608,145.12362,1947.648,percent of total billed charges,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,260.23,8249.769,fee schedule,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2997.444,260.23,3665.664,percent of total billed charges,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,295.788,105.7395,416.02,percent of total billed charges,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,908.088,324.627,1110.528,percent of total billed charges,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,823.936,294.544,1007.616,percent of total billed charges,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,530.66,189.7025,648.96,percent of total billed charges,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,467.232,167.028,571.392,percent of total billed charges,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1832.504,145.12362,2241.024,percent of total billed charges,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1811.78,145.12362,2215.68,percent of total billed charges,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,557.664,145.12362,681.984,percent of total billed charges,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,145.12362,681.984,case rate,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,195.08,765.696,fee schedule,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,CIGNA [1000112],CIGNA [100011201],,1393.3385,,,1393.3385,237.819698,1497.6,fee schedule,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,CIGNA [1000112],CIGNA [100011201],,1393.3385,,,1393.3385,220.908,1393.3385,fee schedule,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,85.759,416.02,fee schedule,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,79.024,836,case rate,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,221.056,79.024,836,percent of total billed charges,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,79.024,836,case rate,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,94.739,836,case rate,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,265.016,94.739,836,percent of total billed charges,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,94.739,836,case rate,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,71.24,712.704,case rate,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,81.08,1703.424,case rate,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,189.029,836,case rate,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,51.4105,575,case rate,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,97.2085,416.02,fee schedule,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,99.678,416.02,fee schedule,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,93.6165,416.02,fee schedule,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.4325,416.02,fee schedule,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,103.4945,416.02,fee schedule,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.5545,416.02,fee schedule,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,58.5945,416.02,fee schedule,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,82.616,416.02,fee schedule,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,77.4525,416.02,fee schedule,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,456.96,fee schedule,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,64.8805,416.02,fee schedule,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,140.672,50.288,416.02,percent of total billed charges,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,94.5145,416.02,fee schedule,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,447.764,157.086513,547.584,percent of total billed charges,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,162.7625,646.6965,fee schedule,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,CIGNA [1000112],CIGNA [100011201],,,62.8,,150.72,53.88,416.02,percent of total billed charges,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,68.0235,416.02,fee schedule,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,460.8,fee schedule,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,79.6975,416.02,fee schedule,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,98.5555,416.02,fee schedule,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,80.371,416.02,fee schedule,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,65.105,416.02,fee schedule,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,443.904,fee schedule,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,32.777,416.02,fee schedule,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,81.9425,416.02,fee schedule,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,199.512292,772.608,fee schedule,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,81.0445,416.02,fee schedule,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,74.534,416.02,fee schedule,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,102.5965,416.02,fee schedule,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,90.0245,416.02,fee schedule,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,61.2885,416.02,fee schedule,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,89.8,416.02,fee schedule,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,56.7985,416.02,fee schedule,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,CIGNA [1000112],CIGNA [100011201],,775.5705,,,775.5705,152.8845,775.5705,fee schedule,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,157.628,56.3495,416.02,percent of total billed charges,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,CIGNA [1000112],CIGNA [100011201],,,62.8,,288.88,103.27,416.02,percent of total billed charges,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,545.104,166.37,666.624,percent of total billed charges,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,416.02,percent of total billed charges,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,379.312,135.598,463.872,percent of total billed charges,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,327.188,116.9645,416.02,percent of total billed charges,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,199.704,71.391,416.02,percent of total billed charges,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,325.304,116.291,416.02,percent of total billed charges,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,399.86,1383.168,case rate,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,63.344499,1341.696,case rate,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,63.344499,1347.84,case rate,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,CIGNA [1000112],CIGNA [100011201],,575,,,575,139.8635,575,case rate,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2374.656,case rate,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,189.029,836,case rate,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,189.029,836,case rate,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,1936.896,case rate,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,1936.896,case rate,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2548.224,case rate,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2548.224,case rate,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,CIGNA [1000112],CIGNA [100011201],,250.1105,,,250.1105,72.0645,416.02,fee schedule,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,CIGNA [1000112],CIGNA [100011201],,318.9185,,,318.9185,88.2285,416.02,fee schedule,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,CIGNA [1000112],CIGNA [100011201],,68.808,,,68.808,22.99364,416.02,fee schedule,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,CIGNA [1000112],CIGNA [100011201],,250.1105,,,250.1105,88.2285,416.02,fee schedule,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,318.9185,,,318.9185,90.800319,416.02,fee schedule,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,264.4455,,,264.4455,90.800319,416.02,fee schedule,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,58.819,416.02,fee schedule,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,48.941,416.02,fee schedule,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,112.699,416.02,fee schedule,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,112.699,416.02,fee schedule,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,441.6,fee schedule,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,25.593,416.02,fee schedule,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,267.439885,1847.808,case rate,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,55.676,416.02,fee schedule,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,55.676,416.02,fee schedule,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,209.9075,1076.394,fee schedule,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,142.1085,1076.394,fee schedule,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,220.459,1076.394,fee schedule,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,235.5005,1397.122,fee schedule,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,107.388,38.3895,416.02,percent of total billed charges,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,353.5875,1209.6,fee schedule,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,304.6465,1076.394,fee schedule,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,358.69,1457.664,fee schedule,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,314.9735,1077.504,fee schedule,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,314.9735,1077.504,fee schedule,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,147.9455,1076.394,fee schedule,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,217.9895,1076.394,fee schedule,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,240.4395,1397.122,fee schedule,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,399.86,2239.93036,fee schedule,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,270.5225,1076.394,fee schedule,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,310.708,1076.394,fee schedule,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,310.708,1397.122,fee schedule,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,176.906,1076.394,fee schedule,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,234.1535,1076.394,fee schedule,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,188.131,1076.394,fee schedule,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,399.86,1596.672,fee schedule,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,200.4785,1076.394,fee schedule,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,214.173,1076.394,fee schedule,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,215.969,1076.394,fee schedule,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,246.501,1076.394,fee schedule,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,200.4785,1076.394,fee schedule,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,214.622,1076.394,fee schedule,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,356.057,1218.048,fee schedule,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,375.1395,1283.328,fee schedule,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,172.1915,1076.394,fee schedule,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,143.68,1076.394,fee schedule,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,212.377,1397.122,fee schedule,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,202.499,1076.394,fee schedule,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,336.5255,1397.122,fee schedule,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,399.86,2076.672,fee schedule,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,356.7305,1397.122,fee schedule,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,CIGNA [1000112],CIGNA [100011201],,1913,,,1913,399.86,3755.52,case rate,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,399.86,1973.76,fee schedule,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,205.642,1397.122,fee schedule,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,290.054,1076.394,fee schedule,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,271.645,1397.122,fee schedule,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,201.8255,1397.122,fee schedule,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,189.7025,1076.394,fee schedule,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,194.6415,1076.394,fee schedule,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,275.4615,1076.394,fee schedule,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,CIGNA [1000112],CIGNA [100011201],,1913,,,1913,399.86,3982.848,case rate,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,CIGNA [1000112],CIGNA [100011201],,1913,,,1913,399.86,5302.272,case rate,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,CIGNA [1000112],CIGNA [100011201],,1913,,,1913,399.86,5917.44,case rate,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,CIGNA [1000112],CIGNA [100011201],,4124.5085,,,4124.5085,399.86,4124.5085,fee schedule,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,127.484,45.5735,416.02,percent of total billed charges,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,CIGNA [1000112],CIGNA [100011201],,691.5815,,,691.5815,175.559,691.5815,fee schedule,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,CIGNA [1000112],CIGNA [100011201],,5.11,,,5.11,2.29,24.576,fee schedule,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,CIGNA [1000112],CIGNA [100011201],,19.6,,,19.6,6.286,21.504,fee schedule,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,CIGNA [1000112],CIGNA [100011201],,421.33,,,421.33,160.742,549.888,fee schedule,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,CIGNA [1000112],CIGNA [100011201],,9.632,,,9.632,3.33,18.432,fee schedule,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,CIGNA [1000112],CIGNA [100011201],,7.462,,,7.462,2.4,34.56,fee schedule,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,CIGNA [1000112],CIGNA [100011201],,108.71,,,108.71,39.73,1313.895373,fee schedule,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,CIGNA [1000112],CIGNA [100011201],,9.73,,,9.73,4.35,61.44,fee schedule,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,CIGNA [1000112],CIGNA [100011201],,21.28,,,21.28,6.78,24.576,fee schedule,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,CIGNA [1000112],CIGNA [100011201],,12.53,,,12.53,5.6125,19.2,fee schedule,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,CIGNA [1000112],CIGNA [100011201],,41.79,,,41.79,18.77,98.304,fee schedule,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,CIGNA [1000112],CIGNA [100011201],,18.382,,,18.382,6.51,121.344,fee schedule,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,CIGNA [1000112],CIGNA [100011201],,18.34,,,18.34,6.5105,24.43,fee schedule,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,CIGNA [1000112],CIGNA [100011201],,23.632,,,23.632,7.4085,25.344,fee schedule,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,CIGNA [1000112],CIGNA [100011201],,32.732,,,32.732,14.71,119.04,fee schedule,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,CIGNA [1000112],CIGNA [100011201],,58.73,,,58.73,26.37,193.536,fee schedule,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,CIGNA [1000112],CIGNA [100011201],,68.642,,,68.642,27.838,95.232,fee schedule,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,241.472,,,241.472,64.4315,241.472,fee schedule,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,CIGNA [1000112],CIGNA [100011201],,22.232,,,22.232,6.25,92.88556,fee schedule,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,CIGNA [1000112],CIGNA [100011201],,2.072,,,2.072,2.072,274.944,fee schedule,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,CIGNA [1000112],CIGNA [100011201],,2.842,,,2.842,2.842,549.235176,fee schedule,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,CIGNA [1000112],CIGNA [100011201],,12.25,,,12.25,5.5,93.463636,fee schedule,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,13.02,,,13.02,5.85,274.176,fee schedule,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,11.802,,,11.802,5.29,274.176,fee schedule,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,CIGNA [1000112],CIGNA [100011201],,6.79,,,6.79,3.05,195.186327,fee schedule,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,CIGNA [1000112],CIGNA [100011201],,6.79,,,6.79,3.05,65.28,fee schedule,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,CIGNA [1000112],CIGNA [100011201],,14.462,,,14.462,3.91,549.235176,fee schedule,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,CIGNA [1000112],CIGNA [100011201],,37.17,,,37.17,9.71,238.848,fee schedule,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,CIGNA [1000112],CIGNA [100011201],,8.722,,,8.722,3.91,549.235176,fee schedule,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,CIGNA [1000112],CIGNA [100011201],,17.64,,,17.64,7.91,218.112,fee schedule,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,CIGNA [1000112],CIGNA [100011201],,2.31,,,2.31,2.31,272.64,fee schedule,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,2.072,,,2.072,2.072,274.176,fee schedule,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,2.45,,,2.45,2.45,274.176,fee schedule,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,1.862,,,1.862,1.862,274.176,fee schedule,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,CIGNA [1000112],CIGNA [100011201],,1.302,,,1.302,1.302,263.69806,fee schedule,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,CIGNA [1000112],CIGNA [100011201],,1.932,,,1.932,1.932,416.02,fee schedule,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,CIGNA [1000112],CIGNA [100011201],,1.932,,,1.932,1.932,93.463636,fee schedule,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,CIGNA [1000112],CIGNA [100011201],,1.54,,,1.54,1.54,499.62884,fee schedule,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,CIGNA [1000112],CIGNA [100011201],,2.702,,,2.702,2.702,274.944,fee schedule,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,CIGNA [1000112],CIGNA [100011201],,2.072,,,2.072,2.072,608.812631,fee schedule,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,CIGNA [1000112],CIGNA [100011201],,2.31,,,2.31,2.31,238.848,fee schedule,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,CIGNA [1000112],CIGNA [100011201],,2.31,,,2.31,2.31,416.02,fee schedule,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,CIGNA [1000112],CIGNA [100011201],,2.31,,,2.31,2.31,416.02,fee schedule,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,CIGNA [1000112],CIGNA [100011201],,2.31,,,2.31,2.31,238.848,fee schedule,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,CIGNA [1000112],CIGNA [100011201],,1.68,,,1.68,1.68,229.632,fee schedule,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,CIGNA [1000112],CIGNA [100011201],,37.59,,,37.59,11.674,39.936,fee schedule,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,CIGNA [1000112],CIGNA [100011201],,114.072,,,114.072,47.145,416.02,fee schedule,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,CIGNA [1000112],CIGNA [100011201],,114.072,,,114.072,34.124,116.736,fee schedule,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,CIGNA [1000112],CIGNA [100011201],,28,,,28,12.32,44.544,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,CIGNA [1000112],CIGNA [100011201],,373.4855,,,373.4855,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,CIGNA [1000112],CIGNA [100011201],,373.4855,,,373.4855,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,CIGNA [1000112],CIGNA [100011201],,373.4855,,,373.4855,139.93,1690.176,fee schedule,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,CIGNA [1000112],CIGNA [100011201],,373.4855,,,373.4855,139.93,1690.176,fee schedule,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,CIGNA [1000112],CIGNA [100011201],,882.3075,,,882.3075,287.71,7105.5744,fee schedule,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,CIGNA [1000112],CIGNA [100011201],,4791.979,,,4791.979,389.10344,4791.979,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,CIGNA [1000112],CIGNA [100011201],,201.536,,,201.536,0.5,416.02,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,CIGNA [1000112],CIGNA [100011201],,201.536,,,201.536,0.5,416.02,fee schedule,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,CIGNA [1000112],CIGNA [100011201],,201.536,,,201.536,0.5,416.02,fee schedule,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,121.204,43.3285,416.02,percent of total billed charges,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,45.844,16.3885,416.02,percent of total billed charges,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,69.708,24.9195,416.02,percent of total billed charges,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,CIGNA [1000112],CIGNA [100011201],,556.198,,,556.198,0.5,671.54688,fee schedule,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,CIGNA [1000112],CIGNA [100011201],,556.198,,,556.198,0.5,671.54688,fee schedule,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,CIGNA [1000112],CIGNA [100011201],,201.8415,,,201.8415,70.48,416.02,fee schedule,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,CIGNA [1000112],CIGNA [100011201],,201.8415,,,201.8415,70.48,416.02,fee schedule,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,CIGNA [1000112],CIGNA [100011201],,91.7205,,,91.7205,34.799745,416.02,fee schedule,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,CIGNA [1000112],CIGNA [100011201],,91.7205,,,91.7205,34.799745,416.02,fee schedule,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,CIGNA [1000112],CIGNA [100011201],,32.759,,,32.759,11.07683,416.02,fee schedule,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,CIGNA [1000112],CIGNA [100011201],,32.759,,,32.759,11.07683,416.02,fee schedule,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,CIGNA [1000112],CIGNA [100011201],,707.397,,,707.397,0.5,881.02656,fee schedule,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,CIGNA [1000112],CIGNA [100011201],,707.397,,,707.397,0.5,881.02656,fee schedule,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,CIGNA [1000112],CIGNA [100011201],,74.8475,,,74.8475,0.5,416.02,fee schedule,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,CIGNA [1000112],CIGNA [100011201],,74.8475,,,74.8475,0.5,416.02,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,CIGNA [1000112],CIGNA [100011201],,997.622,,,997.622,91.911626,1316.02176,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,CIGNA [1000112],CIGNA [100011201],,997.622,,,997.622,91.911626,1316.02176,fee schedule,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,CIGNA [1000112],CIGNA [100011201],,997.622,,,997.622,91.911626,1316.02176,fee schedule,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,CIGNA [1000112],CIGNA [100011201],,668.434,,,668.434,0.5,843.5712,fee schedule,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,CIGNA [1000112],CIGNA [100011201],,165.816,,,165.816,0.5,416.02,fee schedule,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,CIGNA [1000112],CIGNA [100011201],,165.816,,,165.816,0.5,416.02,fee schedule,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,CIGNA [1000112],CIGNA [100011201],,73.743,,,73.743,24.135995,416.02,fee schedule,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,CIGNA [1000112],CIGNA [100011201],,73.743,,,73.743,24.135995,416.02,fee schedule,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,CIGNA [1000112],CIGNA [100011201],,236.5275,,,236.5275,54.47,416.02,fee schedule,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,CIGNA [1000112],CIGNA [100011201],,236.5275,,,236.5275,54.47,416.02,fee schedule,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,CIGNA [1000112],CIGNA [100011201],,106.972,,,106.972,25.298577,416.02,fee schedule,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,CIGNA [1000112],CIGNA [100011201],,106.972,,,106.972,25.298577,416.02,fee schedule,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,CIGNA [1000112],CIGNA [100011201],,121.2835,,,121.2835,25.298577,416.02,fee schedule,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,CIGNA [1000112],CIGNA [100011201],,121.2835,,,121.2835,25.298577,416.02,fee schedule,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,CIGNA [1000112],CIGNA [100011201],,121.2835,,,121.2835,25.298577,416.02,fee schedule,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,CIGNA [1000112],CIGNA [100011201],,121.2835,,,121.2835,25.298577,416.02,fee schedule,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,CIGNA [1000112],CIGNA [100011201],,421.0965,,,421.0965,0.5,566.10816,fee schedule,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,CIGNA [1000112],CIGNA [100011201],,421.0965,,,421.0965,0.5,566.10816,fee schedule,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,CIGNA [1000112],CIGNA [100011201],,237.021,,,237.021,0.5,416.02,fee schedule,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,CIGNA [1000112],CIGNA [100011201],,237.021,,,237.021,0.5,416.02,fee schedule,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,CIGNA [1000112],CIGNA [100011201],,390.8285,,,390.8285,0.5,492.14208,fee schedule,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,CIGNA [1000112],CIGNA [100011201],,390.8285,,,390.8285,0.5,492.14208,fee schedule,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,CIGNA [1000112],CIGNA [100011201],,370.0545,,,370.0545,0.5,416.02,fee schedule,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,CIGNA [1000112],CIGNA [100011201],,370.0545,,,370.0545,0.5,416.02,fee schedule,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.128,252.787,1055.807021,percent of total billed charges,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1114.7,398.4875,1363.2,percent of total billed charges,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,2463.016,399.86,3012.096,percent of total billed charges,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,2463.016,399.86,3012.096,percent of total billed charges,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,472.256,168.824,1592,percent of total billed charges,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,CIGNA [1000112],CIGNA [100011201],,,62.8,,854.08,305.32,1592,percent of total billed charges,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,CIGNA [1000112],CIGNA [100011201],,,62.8,,309.42816,0.5,417.629472,percent of total billed charges,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,CIGNA [1000112],CIGNA [100011201],,,62.8,,309.42816,0.5,417.629472,percent of total billed charges,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,CIGNA [1000112],CIGNA [100011201],,,62.8,,50.24,17.96,416.02,percent of total billed charges,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,CIGNA [1000112],CIGNA [100011201],,,62.8,,797.56,163,975.36,percent of total billed charges,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,553.896,163,677.376,percent of total billed charges,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,CIGNA [1000112],CIGNA [100011201],,,62.8,,345.4,123.475,422.4,percent of total billed charges,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,97.34,34.7975,416.02,percent of total billed charges,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,97.34,34.7975,416.02,percent of total billed charges,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,97.34,34.7975,416.02,percent of total billed charges,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,437.088,142.97,534.528,percent of total billed charges,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.3,50.5125,416.02,percent of total billed charges,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,168.932,60.3905,416.02,percent of total billed charges,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,CIGNA [1000112],CIGNA [100011201],,,62.8,,144.44,51.635,416.02,percent of total billed charges,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,185.26,61.17,416.02,percent of total billed charges,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,90.432,32.328,416.02,percent of total billed charges,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,82.896,29.634,416.02,percent of total billed charges,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,325.932,116.5155,416.02,percent of total billed charges,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,21.98,7.8575,416.02,percent of total billed charges,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,59.66,21.3275,416.02,percent of total billed charges,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,78.5,28.0625,416.02,percent of total billed charges,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,225.452,80.5955,416.02,percent of total billed charges,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,CIGNA [1000112],CIGNA [100011201],,,62.8,,314,112.25,416.02,percent of total billed charges,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,320.908,114.7195,416.02,percent of total billed charges,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,71.592,25.593,416.02,percent of total billed charges,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,391.872,128.12716,479.602522,percent of total billed charges,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.848,26.042,416.02,percent of total billed charges,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,101.736,36.369,416.02,percent of total billed charges,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,457.812,84.99,559.872,percent of total billed charges,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,76.616,20.01,416.02,percent of total billed charges,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,541.964,128.12716,662.784,percent of total billed charges,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,541.964,128.12716,662.784,percent of total billed charges,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,11029.564,399.86,13488.384,percent of total billed charges,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,11029.564,399.86,13488.384,percent of total billed charges,
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,21027.952,399.86,25715.712,percent of total billed charges,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,20632.312,399.86,25231.872,percent of total billed charges,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,20462.752,399.86,25024.512,percent of total billed charges,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,16750.644,399.86,20484.864,percent of total billed charges,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,21281.036,399.86,26793.51305,percent of total billed charges,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,16434.132,399.86,20097.792,percent of total billed charges,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,16750.644,399.86,20484.864,percent of total billed charges,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,16434.132,399.86,20097.792,percent of total billed charges,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,16118.876,399.86,19712.256,percent of total billed charges,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,16434.132,399.86,20097.792,percent of total billed charges,
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,649.352,232.133,997.822944,percent of total billed charges,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,649.352,232.133,997.822944,percent of total billed charges,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,817.656,292.299,999.936,percent of total billed charges,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1259.768,399.86,1540.608,percent of total billed charges,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1259.768,399.86,1540.608,percent of total billed charges,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,485.444,173.5385,593.664,percent of total billed charges,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,145.12362,2138.88,percent of total billed charges,
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,145.12362,2138.88,percent of total billed charges,
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,474.14,169.4975,1592,percent of total billed charges,
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,474.14,169.4975,1592,percent of total billed charges,
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,10821.068,399.86,13233.408,percent of total billed charges,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,10821.068,399.86,16809.6787,percent of total billed charges,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,10821.068,399.86,16809.6787,percent of total billed charges,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,98.596,25.49469,416.02,percent of total billed charges,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,17.584,6.286,416.02,percent of total billed charges,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,304.58,108.8825,479.602522,percent of total billed charges,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,CIGNA [1000112],CIGNA [100011201],,,62.8,,75.36,25.49469,416.02,percent of total billed charges,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,13.816,4.939,416.02,percent of total billed charges,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,271.924,84.459332,416.02,percent of total billed charges,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,199.704,66.75974,416.02,percent of total billed charges,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,39.564,14.1435,416.02,percent of total billed charges,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,74.104,26.491,416.02,percent of total billed charges,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,764.276,41.157815,934.656,percent of total billed charges,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,74.104,26.491,416.02,percent of total billed charges,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,74.104,26.491,416.02,percent of total billed charges,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1179.384,41.157815,1442.304,percent of total billed charges,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,74.104,26.491,416.02,percent of total billed charges,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,74.104,26.491,416.02,percent of total billed charges,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,140.672,41.157815,416.02,percent of total billed charges,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,74.104,26.491,416.02,percent of total billed charges,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,155.744,23.39896,416.02,percent of total billed charges,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,74.104,26.491,416.02,percent of total billed charges,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,839.636,54.1045,1223.3,percent of total billed charges,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,151.348,54.1045,1223.3,percent of total billed charges,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,818.284,281.81,1040.64,percent of total billed charges,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,850.94,281.81,1040.64,percent of total billed charges,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,845.916,54.1045,1034.496,percent of total billed charges,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,845.916,54.1045,1034.496,percent of total billed charges,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,151.348,54.1045,1034.496,percent of total billed charges,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,771.184,267.439885,943.104,percent of total billed charges,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,771.184,267.439885,943.104,percent of total billed charges,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,352.308,125.9445,465.66,percent of total billed charges,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,352.308,125.9445,465.66,percent of total billed charges,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,352.308,125.9445,465.66,percent of total billed charges,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1107.792,224.549385,1354.752,percent of total billed charges,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1107.792,224.549385,1354.752,percent of total billed charges,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,942.628,336.9745,1152.768,percent of total billed charges,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,221.056,79.024,416.02,percent of total billed charges,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,202.844,72.5135,416.02,percent of total billed charges,
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.152,86.208,416.02,percent of total billed charges,
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,467.232,135.906309,571.392,percent of total billed charges,
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,869.152,224.549385,1062.912,percent of total billed charges,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,869.152,224.549385,1062.912,percent of total billed charges,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1120.98,224.549385,1370.88,percent of total billed charges,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1120.98,224.549385,1370.88,percent of total billed charges,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,488.584,174.661,597.504,percent of total billed charges,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,676.356,241.7865,827.136,percent of total billed charges,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5763.156,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6900.464,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6900.464,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6900.464,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,6126.14,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,6126.14,399.86,7870.4,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6900.464,399.86,8438.784,percent of total billed charges,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6900.464,399.86,8438.784,percent of total billed charges,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6900.464,399.86,8438.784,percent of total billed charges,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,6509.22,399.86,7960.32,percent of total billed charges,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1882.744,399.86,2532.39,percent of total billed charges,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1882.744,399.86,2532.39,percent of total billed charges,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1596.376,399.86,1952.256,percent of total billed charges,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,639.304,228.541,1592,percent of total billed charges,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,CIGNA [1000112],CIGNA [100011201],,,62.8,,320.28,114.495,1592,percent of total billed charges,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,639.304,228.541,1592,percent of total billed charges,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,940.744,235.074116,1592,percent of total billed charges,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,4355.808,399.86,5638.7,percent of total billed charges,
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1288.028,399.86,1575.168,percent of total billed charges,
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,33443.512,399.86,40899.072,percent of total billed charges,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,33443.512,399.86,40899.072,percent of total billed charges,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,CIGNA [1000112],CIGNA [100011201],,,62.8,,33152.12,399.86,40542.72,percent of total billed charges,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,CIGNA [1000112],CIGNA [100011201],,,62.8,,33152.12,399.86,40542.72,percent of total billed charges,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,10612.572,399.86,12978.432,percent of total billed charges,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5335.488,399.86,6909.98,percent of total billed charges,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,3700.176,399.86,4525.056,percent of total billed charges,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1931.1,399.86,2361.6,percent of total billed charges,
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1936.124,399.86,2367.744,percent of total billed charges,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1936.124,399.86,2367.744,percent of total billed charges,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,4828.692,399.86,10671.09667,percent of total billed charges,
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,764.276,73.54,934.656,percent of total billed charges,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,160.14,57.2475,416.02,percent of total billed charges,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,170.188,60.8395,416.02,percent of total billed charges,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,199.512292,702.72,fee schedule,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,702.72,fee schedule,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,255.2565,873.216,fee schedule,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,96.086,686,fee schedule,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,597.856,213.724,731.136,percent of total billed charges,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,321.5505,,,321.5505,135.906309,702.72,fee schedule,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,CIGNA [1000112],CIGNA [100011201],,402.743,,,402.743,121.132463,686,fee schedule,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,775.5705,,,775.5705,135.906309,775.5705,fee schedule,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,199.512292,702.72,fee schedule,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,99.0045,686,fee schedule,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,135.906309,686,fee schedule,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,135.906309,686,fee schedule,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,702.72,fee schedule,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,170.171,686,fee schedule,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,170.171,686,fee schedule,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,702.72,fee schedule,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,183.192,686,fee schedule,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,93.841,686,fee schedule,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,199.512292,702.72,fee schedule,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.8815,686,fee schedule,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,686,fee schedule,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,185.26,66.2275,416.02,percent of total billed charges,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,280.088,100.127,479.602522,percent of total billed charges,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,580.9,163,710.4,percent of total billed charges,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,246.176,88.004,416.02,percent of total billed charges,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,246.176,88.004,416.02,percent of total billed charges,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,114.296,40.859,416.02,percent of total billed charges,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,310.232,59.92,416.02,percent of total billed charges,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,280.088,98.67,479.602522,percent of total billed charges,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,185.26,66.2275,416.02,percent of total billed charges,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,166.42,59.4925,416.02,percent of total billed charges,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,33.912,12.123,416.02,percent of total billed charges,
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,CIGNA [1000112],CIGNA [100011201],,,62.8,,56.52,20.205,416.02,percent of total billed charges,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,121.832,43.553,416.02,percent of total billed charges,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,121.832,43.553,416.02,percent of total billed charges,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,230.476,22.74,416.02,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,519.356,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,519.356,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,519.356,185.6615,635.136,percent of total billed charges,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1035.572,370.2005,1266.432,percent of total billed charges,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,995.38,355.8325,1217.28,percent of total billed charges,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,995.38,355.8325,1217.28,percent of total billed charges,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,509.936,182.294,623.616,percent of total billed charges,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,601.624,215.071,735.744,percent of total billed charges,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,440.228,157.3745,538.368,percent of total billed charges,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,493.608,176.457,603.648,percent of total billed charges,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,423.9,151.5375,518.4,percent of total billed charges,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,423.9,151.5375,829.50194,percent of total billed charges,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,208.496,14.817,570,percent of total billed charges,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,41.448,14.817,570,percent of total billed charges,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,208.496,30.083,570,percent of total billed charges,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,84.152,30.083,570,percent of total billed charges,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,CIGNA [1000112],CIGNA [100011201],,,62.8,,113.04,20.4295,570,percent of total billed charges,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,57.148,20.4295,570,percent of total billed charges,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,CIGNA [1000112],CIGNA [100011201],,,62.8,,477.28,94.4,583.68,percent of total billed charges,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,437.088,94.4,570,percent of total billed charges,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,454.672,94.4,570,percent of total billed charges,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.012,197.3355,675.072,percent of total billed charges,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,437.088,156.252,534.528,percent of total billed charges,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,209.752,74.983,416.02,percent of total billed charges,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,55.892,19.9805,585.854902,percent of total billed charges,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,262.504,93.841,416.02,percent of total billed charges,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,82.896,29.634,585.854902,percent of total billed charges,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,114.924,41.0835,416.02,percent of total billed charges,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,68.452,24.4705,416.02,percent of total billed charges,
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,101.736,16.16,416.02,percent of total billed charges,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,209.752,74.983,416.02,percent of total billed charges,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,194.052,69.3705,416.02,percent of total billed charges,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,65.94,23.5725,416.02,percent of total billed charges,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,190.284,68.0235,416.02,percent of total billed charges,
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,139.416,49.839,416.02,percent of total billed charges,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,433.948,155.1295,530.688,percent of total billed charges,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,454.672,162.538,556.032,percent of total billed charges,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,117.436,41.9815,585.854902,percent of total billed charges,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,419.504,70.143083,517.481916,percent of total billed charges,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,412.596,147.4965,585.854902,percent of total billed charges,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,CIGNA [1000112],CIGNA [100011201],,,62.8,,332.84,34.385146,416.02,percent of total billed charges,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,153.86,14.38,416.02,percent of total billed charges,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,77.244,27.6135,416.02,percent of total billed charges,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,77.244,14.73,416.02,percent of total billed charges,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,116.18,20.02,416.02,percent of total billed charges,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.22,14.44,416.02,percent of total billed charges,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.22,14.44,416.02,percent of total billed charges,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,123.716,30.33,416.02,percent of total billed charges,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,123.716,30.33,416.02,percent of total billed charges,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.22,25.8175,416.02,percent of total billed charges,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.22,25.8175,416.02,percent of total billed charges,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.22,25.8175,416.02,percent of total billed charges,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,CIGNA [1000112],CIGNA [100011201],,,62.8,,87.92,27.89,416.02,percent of total billed charges,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,CIGNA [1000112],CIGNA [100011201],,,62.8,,87.92,27.89,416.02,percent of total billed charges,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.64,18.56,416.02,percent of total billed charges,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.64,18.56,416.02,percent of total billed charges,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,CIGNA [1000112],CIGNA [100011201],,,62.8,,163.28,58.37,416.02,percent of total billed charges,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,CIGNA [1000112],CIGNA [100011201],,,62.8,,163.28,58.37,416.02,percent of total billed charges,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,CIGNA [1000112],CIGNA [100011201],,,62.8,,163.28,58.37,416.02,percent of total billed charges,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,145.068,51.8595,416.02,percent of total billed charges,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.22,25.8175,416.02,percent of total billed charges,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.22,25.8175,416.02,percent of total billed charges,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,72.22,25.8175,416.02,percent of total billed charges,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,65.312,23.348,416.02,percent of total billed charges,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,114.296,34.45,416.02,percent of total billed charges,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,66.568,23.797,416.02,percent of total billed charges,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,32.656,11.674,416.02,percent of total billed charges,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,CIGNA [1000112],CIGNA [100011201],,,62.8,,144.44,51.635,416.02,percent of total billed charges,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,CIGNA [1000112],CIGNA [100011201],,,62.8,,150.72,53.88,416.02,percent of total billed charges,
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,CIGNA [1000112],CIGNA [100011201],,,62.8,,150.72,53.88,416.02,percent of total billed charges,
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,226.708,81.0445,416.02,percent of total billed charges,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,CIGNA [1000112],CIGNA [100011201],,,62.8,,150.72,53.88,416.02,percent of total billed charges,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,CIGNA [1000112],CIGNA [100011201],,,62.8,,207.24,74.085,416.02,percent of total billed charges,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,195.936,70.044,416.02,percent of total billed charges,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,CIGNA [1000112],CIGNA [100011201],,,,,,82.56,416.02,other,Clinic No Pay
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,CIGNA [1000112],CIGNA [100011201],,,,,,126.37,473.871,other,Clinic No Pay
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,CIGNA [1000112],CIGNA [100011201],,,,,,179.35,693.026,other,Clinic No Pay
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,CIGNA [1000112],CIGNA [100011201],,,,,,146.954008,985.784,other,Clinic No Pay
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,,,,,18.1184,416.02,other,Clinic No Pay
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,,,,,18.1184,416.02,other,E&M No Pay
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,,,,,18.1184,416.02,other,E&M No Pay
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,CIGNA [1000112],CIGNA [100011201],,,,,,50.2428,416.02,other,Clinic No Pay
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,CIGNA [1000112],CIGNA [100011201],,,,,,50.2428,416.02,other,E&M No Pay
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,CIGNA [1000112],CIGNA [100011201],,,,,,50.2428,416.02,other,E&M No Pay
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,CIGNA [1000112],CIGNA [100011201],,,,,,90.68,416.02,other,Clinic No Pay
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,CIGNA [1000112],CIGNA [100011201],,,,,,90.68,416.02,other,E&M No Pay
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,CIGNA [1000112],CIGNA [100011201],,,,,,104.8415,416.02,other,Clinic No Pay
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,CIGNA [1000112],CIGNA [100011201],,,,,,104.8415,416.02,other,E&M No Pay
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,CIGNA [1000112],CIGNA [100011201],,,,,,169.273,685.583,other,Clinic No Pay
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,CIGNA [1000112],CIGNA [100011201],,,,,,169.273,685.583,other,E&M No Pay
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,CIGNA [1000112],CIGNA [100011201],,,,,,318.748996,2424.576,other,E&M No Pay
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,CIGNA [1000112],CIGNA [100011201],,,,,,318.748996,2424.576,other,E&M No Pay
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,CIGNA [1000112],CIGNA [100011201],,,,,,204.5195,699.648,other,E&M No Pay
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,CIGNA [1000112],CIGNA [100011201],,,,,,204.5195,699.648,other,E&M No Pay
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,134.392,31.31797,416.02,percent of total billed charges,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,134.392,31.31797,416.02,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,486.072,173.763,2998,percent of total billed charges,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,101.108,36.1445,2998,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,22389.354,percent of total billed charges,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.58,165.0075,2998,percent of total billed charges,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,CIGNA [1000112],CIGNA [100011201],,,,,,0.1,1477.69344,other,Supplied included in Fac Charge
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,CIGNA [1000112],CIGNA [100011201],,,,,,10.30904,416.02,other,Supplied included in Fac Charge
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,CIGNA [1000112],CIGNA [100011201],,,,,,3.850175,416.02,other,Supplied included in Fac Charge
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,CIGNA [1000112],CIGNA [100011201],,,,,,4.025285,416.02,other,Supplied included in Fac Charge
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,CIGNA [1000112],CIGNA [100011201],,,,,,4.025285,416.02,other,Supplied included in Fac Charge
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,CIGNA [1000112],CIGNA [100011201],,,,,,4.025285,416.02,other,Supplied included in Fac Charge
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,CIGNA [1000112],CIGNA [100011201],,,,,,4.025285,416.02,other,Supplied included in Fac Charge
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,CIGNA [1000112],CIGNA [100011201],,,,,,2.98585,416.02,other,Supplied included in Fac Charge
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,CIGNA [1000112],CIGNA [100011201],,,,,,2.98585,416.02,other,Supplied included in Fac Charge
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,CIGNA [1000112],CIGNA [100011201],,,,,,2.98585,416.02,other,Supplied included in Fac Charge
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,CIGNA [1000112],CIGNA [100011201],,,,,,2.98585,416.02,other,Supplied included in Fac Charge
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,CIGNA [1000112],CIGNA [100011201],,,,,,2.98585,416.02,other,Supplied included in Fac Charge
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,262.504,39.325665,1791.14496,percent of total billed charges,
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,CIGNA [1000112],CIGNA [100011201],,,62.8,,170.39524,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,CIGNA [1000112],CIGNA [100011201],,,62.8,,234.52032,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,CIGNA [1000112],CIGNA [100011201],,,62.8,,689.0416,39.325665,1791.14496,percent of total billed charges,
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,CIGNA [1000112],CIGNA [100011201],,,62.8,,312.42372,39.325665,1791.14496,percent of total billed charges,
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,CIGNA [1000112],CIGNA [100011201],,,62.8,,234.52032,39.325665,1791.14496,percent of total billed charges,
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,CIGNA [1000112],CIGNA [100011201],,,62.8,,110.00676,39.325665,1791.14496,percent of total billed charges,
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,CIGNA [1000112],CIGNA [100011201],,,62.8,,110.00676,39.325665,1791.14496,percent of total billed charges,
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,CIGNA [1000112],CIGNA [100011201],,,62.8,,110.00676,39.325665,1791.14496,percent of total billed charges,
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,CIGNA [1000112],CIGNA [100011201],,,62.8,,472.70816,39.325665,1791.14496,percent of total billed charges,
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,CIGNA [1000112],CIGNA [100011201],,,62.8,,709.01828,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,CIGNA [1000112],CIGNA [100011201],,,62.8,,234.52032,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,CIGNA [1000112],CIGNA [100011201],,,62.8,,302.1308,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,CIGNA [1000112],CIGNA [100011201],,,62.8,,234.52032,39.325665,1791.14496,percent of total billed charges,
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,CIGNA [1000112],CIGNA [100011201],,,62.8,,234.52032,39.325665,1791.14496,percent of total billed charges,
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,CIGNA [1000112],CIGNA [100011201],,,62.8,,1464.63416,39.325665,1791.14496,percent of total billed charges,
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,CIGNA [1000112],CIGNA [100011201],,,62.8,,1464.63416,39.325665,1791.14496,percent of total billed charges,
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,CIGNA [1000112],CIGNA [100011201],,,62.8,,1464.63416,39.325665,1791.14496,percent of total billed charges,
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,CIGNA [1000112],CIGNA [100011201],,,62.8,,1464.63416,39.325665,1791.14496,percent of total billed charges,
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,CIGNA [1000112],CIGNA [100011201],,,62.8,,233.60344,39.325665,1791.14496,percent of total billed charges,
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,CIGNA [1000112],CIGNA [100011201],,,,,,14.186155,5948.3904,other,Supplied included in Fac Charge
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,CIGNA [1000112],CIGNA [100011201],,,,,,7.401765,416.02,other,Supplied included in Fac Charge
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,CIGNA [1000112],CIGNA [100011201],,,,,,7.401765,416.02,other,Supplied included in Fac Charge
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,CIGNA [1000112],CIGNA [100011201],,,,,,11.99,416.02,other,Supplied included in Fac Charge
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,CIGNA [1000112],CIGNA [100011201],,,,,,1.708445,416.02,other,Supplied included in Fac Charge
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,CIGNA [1000112],CIGNA [100011201],,,,,,1.708445,416.02,other,Supplied included in Fac Charge
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,CIGNA [1000112],CIGNA [100011201],,,,,,1.708445,416.02,other,Supplied included in Fac Charge
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,CIGNA [1000112],CIGNA [100011201],,,,,,1.708445,416.02,other,Supplied included in Fac Charge
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,CIGNA [1000112],CIGNA [100011201],,,,,,1.708445,416.02,other,Supplied included in Fac Charge
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,CIGNA [1000112],CIGNA [100011201],,,,,,1.708445,416.02,other,Supplied included in Fac Charge
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,CIGNA [1000112],CIGNA [100011201],,,,,,4.070185,416.02,other,Supplied included in Fac Charge
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,CIGNA [1000112],CIGNA [100011201],,,,,,4.070185,416.02,other,Supplied included in Fac Charge
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,CIGNA [1000112],CIGNA [100011201],,,,,,4.070185,416.02,other,Supplied included in Fac Charge
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,CIGNA [1000112],CIGNA [100011201],,,,,,4.070185,416.02,other,Supplied included in Fac Charge
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,CIGNA [1000112],CIGNA [100011201],,,,,,4.070185,416.02,other,Supplied included in Fac Charge
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,CIGNA [1000112],CIGNA [100011201],,,,,,4.070185,416.02,other,Supplied included in Fac Charge
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,CIGNA [1000112],CIGNA [100011201],,,,,,4.3553,416.02,other,Supplied included in Fac Charge
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,CIGNA [1000112],CIGNA [100011201],,,,,,4.3553,416.02,other,Supplied included in Fac Charge
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,CIGNA [1000112],CIGNA [100011201],,,,,,4.3553,416.02,other,Supplied included in Fac Charge
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,CIGNA [1000112],CIGNA [100011201],,,,,,5.23,416.02,other,Supplied included in Fac Charge
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,CIGNA [1000112],CIGNA [100011201],,,,,,9.98576,416.02,other,Supplied included in Fac Charge
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,CIGNA [1000112],CIGNA [100011201],,,,,,9.98576,416.02,other,Supplied included in Fac Charge
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,CIGNA [1000112],CIGNA [100011201],,,,,,2.94544,416.02,other,Supplied included in Fac Charge
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,CIGNA [1000112],CIGNA [100011201],,,,,,2.94544,416.02,other,Supplied included in Fac Charge
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,CIGNA [1000112],CIGNA [100011201],,,,,,2.94544,416.02,other,Supplied included in Fac Charge
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,CIGNA [1000112],CIGNA [100011201],,,,,,2.94544,416.02,other,Supplied included in Fac Charge
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,CIGNA [1000112],CIGNA [100011201],,,,,,9.121435,416.02,other,Supplied included in Fac Charge
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,CIGNA [1000112],CIGNA [100011201],,,,,,9.121435,416.02,other,Supplied included in Fac Charge
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,CIGNA [1000112],CIGNA [100011201],,,,,,20.692165,416.02,other,Supplied included in Fac Charge
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,CIGNA [1000112],CIGNA [100011201],,,,,,1.79151,416.02,other,Supplied included in Fac Charge
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,CIGNA [1000112],CIGNA [100011201],,,,,,1.79151,416.02,other,Supplied included in Fac Charge
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,CIGNA [1000112],CIGNA [100011201],,,,,,1.79151,416.02,other,Supplied included in Fac Charge
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,CIGNA [1000112],CIGNA [100011201],,,,,,1.79151,416.02,other,Supplied included in Fac Charge
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,CIGNA [1000112],CIGNA [100011201],,,,,,1.79151,416.02,other,Supplied included in Fac Charge
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,CIGNA [1000112],CIGNA [100011201],,,,,,1.79151,416.02,other,Supplied included in Fac Charge
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,CIGNA [1000112],CIGNA [100011201],,,,,,1.79151,416.02,other,Supplied included in Fac Charge
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,CIGNA [1000112],CIGNA [100011201],,,,,,9.206745,416.02,other,Supplied included in Fac Charge
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,CIGNA [1000112],CIGNA [100011201],,,,,,9.206745,416.02,other,Supplied included in Fac Charge
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,CIGNA [1000112],CIGNA [100011201],,,,,,0.04041,416.02,other,Supplied included in Fac Charge
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,CIGNA [1000112],CIGNA [100011201],,,,,,0.04041,416.02,other,Supplied included in Fac Charge
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,CIGNA [1000112],CIGNA [100011201],,,,,,0.04041,416.02,other,Supplied included in Fac Charge
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,CIGNA [1000112],CIGNA [100011201],,,,,,0.04041,416.02,other,Supplied included in Fac Charge
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,CIGNA [1000112],CIGNA [100011201],,,,,,0.52533,416.02,other,Supplied included in Fac Charge
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,CIGNA [1000112],CIGNA [100011201],,,,,,0.52533,416.02,other,Supplied included in Fac Charge
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,CIGNA [1000112],CIGNA [100011201],,,,,,0.52533,416.02,other,Supplied included in Fac Charge
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,CIGNA [1000112],CIGNA [100011201],,,,,,0.52533,416.02,other,Supplied included in Fac Charge
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,CIGNA [1000112],CIGNA [100011201],,,,,,0.52533,416.02,other,Supplied included in Fac Charge
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,CIGNA [1000112],CIGNA [100011201],,,,,,0.52533,416.02,other,Supplied included in Fac Charge
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,CIGNA [1000112],CIGNA [100011201],,,,,,0.52533,416.02,other,Supplied included in Fac Charge
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,CIGNA [1000112],CIGNA [100011201],,,,,,0.698195,416.02,other,Supplied included in Fac Charge
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,CIGNA [1000112],CIGNA [100011201],,,,,,0.698195,416.02,other,Supplied included in Fac Charge
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,CIGNA [1000112],CIGNA [100011201],,,,,,0.698195,416.02,other,Supplied included in Fac Charge
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,CIGNA [1000112],CIGNA [100011201],,,,,,0.698195,416.02,other,Supplied included in Fac Charge
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,CIGNA [1000112],CIGNA [100011201],,,,,,0.698195,416.02,other,Supplied included in Fac Charge
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,CIGNA [1000112],CIGNA [100011201],,,,,,0.698195,416.02,other,Supplied included in Fac Charge
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,CIGNA [1000112],CIGNA [100011201],,,,,,0.698195,416.02,other,Supplied included in Fac Charge
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,CIGNA [1000112],CIGNA [100011201],,,,,,0.801465,416.02,other,Supplied included in Fac Charge
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,CIGNA [1000112],CIGNA [100011201],,,,,,0.801465,416.02,other,Supplied included in Fac Charge
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,CIGNA [1000112],CIGNA [100011201],,,,,,0.801465,416.02,other,Supplied included in Fac Charge
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,CIGNA [1000112],CIGNA [100011201],,,,,,0.801465,416.02,other,Supplied included in Fac Charge
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,CIGNA [1000112],CIGNA [100011201],,,,,,0.801465,416.02,other,Supplied included in Fac Charge
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,CIGNA [1000112],CIGNA [100011201],,,,,,0.913715,416.02,other,Supplied included in Fac Charge
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,CIGNA [1000112],CIGNA [100011201],,,,,,0.913715,416.02,other,Supplied included in Fac Charge
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,CIGNA [1000112],CIGNA [100011201],,,,,,0.913715,416.02,other,Supplied included in Fac Charge
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,CIGNA [1000112],CIGNA [100011201],,,,,,0.913715,416.02,other,Supplied included in Fac Charge
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,CIGNA [1000112],CIGNA [100011201],,,,,,2.67604,416.02,other,Supplied included in Fac Charge
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,CIGNA [1000112],CIGNA [100011201],,,,,,1.659055,416.02,other,Supplied included in Fac Charge
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,CIGNA [1000112],CIGNA [100011201],,,,,,1.659055,416.02,other,Supplied included in Fac Charge
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,CIGNA [1000112],CIGNA [100011201],,,,,,1.659055,416.02,other,Supplied included in Fac Charge
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,CIGNA [1000112],CIGNA [100011201],,,,,,4.600005,416.02,other,Supplied included in Fac Charge
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,CIGNA [1000112],CIGNA [100011201],,,,,,4.600005,416.02,other,Supplied included in Fac Charge
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,CIGNA [1000112],CIGNA [100011201],,,,,,4.600005,416.02,other,Supplied included in Fac Charge
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,CIGNA [1000112],CIGNA [100011201],,,,,,7.087465,416.02,other,Supplied included in Fac Charge
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,CIGNA [1000112],CIGNA [100011201],,,,,,3.66833,416.02,other,Supplied included in Fac Charge
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,CIGNA [1000112],CIGNA [100011201],,,,,,3.66833,416.02,other,Supplied included in Fac Charge
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,CIGNA [1000112],CIGNA [100011201],,,,,,3.122795,416.02,other,Supplied included in Fac Charge
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,CIGNA [1000112],CIGNA [100011201],,,,,,3.122795,416.02,other,Supplied included in Fac Charge
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,CIGNA [1000112],CIGNA [100011201],,,,,,1.98009,416.02,other,Supplied included in Fac Charge
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,CIGNA [1000112],CIGNA [100011201],,,,,,0.262665,416.02,other,Supplied included in Fac Charge
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,CIGNA [1000112],CIGNA [100011201],,,,,,0.262665,416.02,other,Supplied included in Fac Charge
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,CIGNA [1000112],CIGNA [100011201],,,,,,0.262665,416.02,other,Supplied included in Fac Charge
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,CIGNA [1000112],CIGNA [100011201],,,,,,0.262665,416.02,other,Supplied included in Fac Charge
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,CIGNA [1000112],CIGNA [100011201],,,,,,0.262665,416.02,other,Supplied included in Fac Charge
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,CIGNA [1000112],CIGNA [100011201],,,,,,0.75881,416.02,other,Supplied included in Fac Charge
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,CIGNA [1000112],CIGNA [100011201],,,,,,0.75881,416.02,other,Supplied included in Fac Charge
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,CIGNA [1000112],CIGNA [100011201],,,,,,0.75881,416.02,other,Supplied included in Fac Charge
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,CIGNA [1000112],CIGNA [100011201],,,,,,0.75881,416.02,other,Supplied included in Fac Charge
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,CIGNA [1000112],CIGNA [100011201],,,,,,0.75881,416.02,other,Supplied included in Fac Charge
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,CIGNA [1000112],CIGNA [100011201],,,,,,2.21357,416.02,other,Supplied included in Fac Charge
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,CIGNA [1000112],CIGNA [100011201],,,62.8,,63.15168,4.17,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,CIGNA [1000112],CIGNA [100011201],,,62.8,,64.37,4.17,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,CIGNA [1000112],CIGNA [100011201],,,62.8,,63.15796,4.17,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,CIGNA [1000112],CIGNA [100011201],,,62.8,,63.15168,4.17,416.02,percent of total billed charges,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,CIGNA [1000112],CIGNA [100011201],,,62.8,,63.15168,4.17,416.02,percent of total billed charges,
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,CIGNA [1000112],CIGNA [100011201],,,,,,0.12,416.02,other,Supplied included in Fac Charge
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,CIGNA [1000112],CIGNA [100011201],,,62.8,,2421.54288,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,CIGNA [1000112],CIGNA [100011201],,,62.8,,1408.17696,0.518595,35041.66656,percent of total billed charges,
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,CIGNA [1000112],CIGNA [100011201],,,62.8,,3598.0632,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,CIGNA [1000112],CIGNA [100011201],,,62.8,,1308.35008,0.518595,35041.66656,percent of total billed charges,
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,CIGNA [1000112],CIGNA [100011201],,,62.8,,462.00704,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.07,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.07,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.07,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.07,0.518595,35041.66656,percent of total billed charges,
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.07,0.518595,35041.66656,percent of total billed charges,
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.07,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,CIGNA [1000112],CIGNA [100011201],,,62.8,,2356.48208,0.518595,35041.66656,percent of total billed charges,
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,3943.212,0.518595,35041.66656,percent of total billed charges,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,CIGNA [1000112],CIGNA [100011201],,,62.8,,249.17784,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,CIGNA [1000112],CIGNA [100011201],,,62.8,,5916.81504,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,CIGNA [1000112],CIGNA [100011201],,,62.8,,713.57756,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,CIGNA [1000112],CIGNA [100011201],,,62.8,,713.57756,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,CIGNA [1000112],CIGNA [100011201],,,62.8,,713.57756,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,CIGNA [1000112],CIGNA [100011201],,,62.8,,672.78268,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,CIGNA [1000112],CIGNA [100011201],,,62.8,,712.35296,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,CIGNA [1000112],CIGNA [100011201],,,62.8,,671.06824,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,CIGNA [1000112],CIGNA [100011201],,,62.8,,67.93704,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,CIGNA [1000112],CIGNA [100011201],,,62.8,,67.93704,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,CIGNA [1000112],CIGNA [100011201],,,62.8,,707.02124,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,CIGNA [1000112],CIGNA [100011201],,,62.8,,67.93704,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,CIGNA [1000112],CIGNA [100011201],,,62.8,,67.93704,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,CIGNA [1000112],CIGNA [100011201],,,62.8,,44.57544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,CIGNA [1000112],CIGNA [100011201],,,62.8,,92.40392,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,CIGNA [1000112],CIGNA [100011201],,,62.8,,92.34112,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,CIGNA [1000112],CIGNA [100011201],,,62.8,,44.5566,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,CIGNA [1000112],CIGNA [100011201],,,62.8,,152.18324,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,CIGNA [1000112],CIGNA [100011201],,,62.8,,152.18324,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,CIGNA [1000112],CIGNA [100011201],,,62.8,,152.18324,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,CIGNA [1000112],CIGNA [100011201],,,62.8,,152.18324,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,CIGNA [1000112],CIGNA [100011201],,,62.8,,67.93704,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,CIGNA [1000112],CIGNA [100011201],,,62.8,,97.82984,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,CIGNA [1000112],CIGNA [100011201],,,62.8,,97.80472,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,CIGNA [1000112],CIGNA [100011201],,,62.8,,802.88544,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,CIGNA [1000112],CIGNA [100011201],,,62.8,,878.77924,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,CIGNA [1000112],CIGNA [100011201],,,62.8,,1345.40208,0.518595,35041.66656,percent of total billed charges,
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,CIGNA [1000112],CIGNA [100011201],,,62.8,,1345.40208,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,CIGNA [1000112],CIGNA [100011201],,,62.8,,1604.5714,0.518595,35041.66656,percent of total billed charges,
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,CIGNA [1000112],CIGNA [100011201],,,62.8,,1604.5714,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,CIGNA [1000112],CIGNA [100011201],,,62.8,,73.37552,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,CIGNA [1000112],CIGNA [100011201],,,62.8,,1098.54156,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,CIGNA [1000112],CIGNA [100011201],,,62.8,,814.63532,0.518595,35041.66656,percent of total billed charges,
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,CIGNA [1000112],CIGNA [100011201],,,62.8,,8856.03716,0.518595,35041.66656,percent of total billed charges,
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,CIGNA [1000112],CIGNA [100011201],,,62.8,,3695.61044,0.518595,35041.66656,percent of total billed charges,
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,CIGNA [1000112],CIGNA [100011201],,,62.8,,4506.50916,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,CIGNA [1000112],CIGNA [100011201],,,62.8,,417.73932,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,CIGNA [1000112],CIGNA [100011201],,,62.8,,417.73932,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,CIGNA [1000112],CIGNA [100011201],,,62.8,,417.73932,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,CIGNA [1000112],CIGNA [100011201],,,62.8,,380.4738,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,CIGNA [1000112],CIGNA [100011201],,,62.8,,380.4738,0.518595,35041.66656,percent of total billed charges,
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,CIGNA [1000112],CIGNA [100011201],,,62.8,,584.28492,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,CIGNA [1000112],CIGNA [100011201],,,62.8,,489.15548,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,CIGNA [1000112],CIGNA [100011201],,,62.8,,489.15548,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,CIGNA [1000112],CIGNA [100011201],,,62.8,,489.15548,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,CIGNA [1000112],CIGNA [100011201],,,62.8,,462.00704,0.518595,35041.66656,percent of total billed charges,
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,CIGNA [1000112],CIGNA [100011201],,,62.8,,3755.42116,0.518595,35041.66656,percent of total billed charges,
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,CIGNA [1000112],CIGNA [100011201],,,62.8,,184.79528,0.518595,35041.66656,percent of total billed charges,
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,CIGNA [1000112],CIGNA [100011201],,,62.8,,6000.47092,0.518595,35041.66656,percent of total billed charges,
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,CIGNA [1000112],CIGNA [100011201],,,62.8,,1505.84352,0.518595,35041.66656,percent of total billed charges,
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,CIGNA [1000112],CIGNA [100011201],,,62.8,,2734.7516,0.518595,35041.66656,percent of total billed charges,
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.06244,0.518595,35041.66656,percent of total billed charges,
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,CIGNA [1000112],CIGNA [100011201],,,62.8,,1308.35008,0.518595,35041.66656,percent of total billed charges,
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,CIGNA [1000112],CIGNA [100011201],,,62.8,,1123.2094,0.518595,35041.66656,percent of total billed charges,
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,CIGNA [1000112],CIGNA [100011201],,,62.8,,1700.89404,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,CIGNA [1000112],CIGNA [100011201],,,62.8,,2401.24592,0.518595,35041.66656,percent of total billed charges,
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,CIGNA [1000112],CIGNA [100011201],,,62.8,,2078.86212,0.518595,35041.66656,percent of total billed charges,
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,CIGNA [1000112],CIGNA [100011201],,,62.8,,2223.3712,0.518595,35041.66656,percent of total billed charges,
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,CIGNA [1000112],CIGNA [100011201],,,62.8,,4012.37364,0.518595,35041.66656,percent of total billed charges,
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,CIGNA [1000112],CIGNA [100011201],,,62.8,,2623.58304,0.518595,35041.66656,percent of total billed charges,
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,CIGNA [1000112],CIGNA [100011201],,,62.8,,2379.02728,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,CIGNA [1000112],CIGNA [100011201],,,62.8,,206.56176,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.07,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.07,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.62852,0.518595,35041.66656,percent of total billed charges,
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,CIGNA [1000112],CIGNA [100011201],,,62.8,,998.6142,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,CIGNA [1000112],CIGNA [100011201],,,62.8,,549.657,0.518595,35041.66656,percent of total billed charges,
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,CIGNA [1000112],CIGNA [100011201],,,62.8,,475.56556,0.518595,35041.66656,percent of total billed charges,
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,CIGNA [1000112],CIGNA [100011201],,,62.8,,475.56556,0.518595,35041.66656,percent of total billed charges,
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,CIGNA [1000112],CIGNA [100011201],,,62.8,,238.18784,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.12944,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,CIGNA [1000112],CIGNA [100011201],,,62.8,,80.9492,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,CIGNA [1000112],CIGNA [100011201],,,62.8,,92.52324,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,CIGNA [1000112],CIGNA [100011201],,,62.8,,439.7256,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.21844,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,CIGNA [1000112],CIGNA [100011201],,,62.8,,100.54908,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.53324,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,CIGNA [1000112],CIGNA [100011201],,,62.8,,122.31556,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,CIGNA [1000112],CIGNA [100011201],,,62.8,,122.31556,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,CIGNA [1000112],CIGNA [100011201],,,62.8,,122.31556,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,CIGNA [1000112],CIGNA [100011201],,,62.8,,141.33768,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,CIGNA [1000112],CIGNA [100011201],,,62.8,,86.99056,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,CIGNA [1000112],CIGNA [100011201],,,62.8,,130.45444,0.518595,35041.66656,percent of total billed charges,
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,CIGNA [1000112],CIGNA [100011201],,,62.8,,242.76596,0.518595,35041.66656,percent of total billed charges,
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,CIGNA [1000112],CIGNA [100011201],,,62.8,,244.59972,0.518595,35041.66656,percent of total billed charges,
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,CIGNA [1000112],CIGNA [100011201],,,62.8,,228.29056,0.518595,35041.66656,percent of total billed charges,
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,CIGNA [1000112],CIGNA [100011201],,,62.8,,271.74816,0.518595,35041.66656,percent of total billed charges,
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.06244,0.518595,35041.66656,percent of total billed charges,
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,CIGNA [1000112],CIGNA [100011201],,,62.8,,255.48296,0.518595,35041.66656,percent of total billed charges,
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,CIGNA [1000112],CIGNA [100011201],,,62.8,,502.75168,0.518595,35041.66656,percent of total billed charges,
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,CIGNA [1000112],CIGNA [100011201],,,62.8,,266.32852,0.518595,35041.66656,percent of total billed charges,
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,CIGNA [1000112],CIGNA [100011201],,,62.8,,516.34788,0.518595,35041.66656,percent of total billed charges,
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,CIGNA [1000112],CIGNA [100011201],,,62.8,,266.32852,0.518595,35041.66656,percent of total billed charges,
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,CIGNA [1000112],CIGNA [100011201],,,62.8,,529.94408,0.518595,35041.66656,percent of total billed charges,
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,CIGNA [1000112],CIGNA [100011201],,,62.8,,285.34436,0.518595,35041.66656,percent of total billed charges,
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,CIGNA [1000112],CIGNA [100011201],,,62.8,,557.0988,0.518595,35041.66656,percent of total billed charges,
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.68872,0.518595,35041.66656,percent of total billed charges,
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,CIGNA [1000112],CIGNA [100011201],,,62.8,,691.2082,0.518595,35041.66656,percent of total billed charges,
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,CIGNA [1000112],CIGNA [100011201],,,62.8,,448.41084,0.518595,35041.66656,percent of total billed charges,
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,CIGNA [1000112],CIGNA [100011201],,,62.8,,597.88112,0.518595,35041.66656,percent of total billed charges,
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,CIGNA [1000112],CIGNA [100011201],,,62.8,,638.62576,0.518595,35041.66656,percent of total billed charges,
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,CIGNA [1000112],CIGNA [100011201],,,62.8,,665.81816,0.518595,35041.66656,percent of total billed charges,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,CIGNA [1000112],CIGNA [100011201],,,62.8,,1172.5702,0.518595,35041.66656,percent of total billed charges,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,CIGNA [1000112],CIGNA [100011201],,,62.8,,1611.94412,0.518595,35041.66656,percent of total billed charges,
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,CIGNA [1000112],CIGNA [100011201],,,62.8,,679.37668,0.518595,35041.66656,percent of total billed charges,
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,CIGNA [1000112],CIGNA [100011201],,,62.8,,826.98808,0.518595,35041.66656,percent of total billed charges,
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,CIGNA [1000112],CIGNA [100011201],,,62.8,,851.68732,0.518595,35041.66656,percent of total billed charges,
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,CIGNA [1000112],CIGNA [100011201],,,62.8,,509.35196,0.518595,35041.66656,percent of total billed charges,
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,CIGNA [1000112],CIGNA [100011201],,,62.8,,568.34628,0.518595,35041.66656,percent of total billed charges,
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,CIGNA [1000112],CIGNA [100011201],,,62.8,,31.33092,0.518595,35041.66656,percent of total billed charges,
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,CIGNA [1000112],CIGNA [100011201],,,62.8,,9490.27948,0.518595,35041.66656,percent of total billed charges,
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,CIGNA [1000112],CIGNA [100011201],,,62.8,,9979.94992,0.518595,35041.66656,percent of total billed charges,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,CIGNA [1000112],CIGNA [100011201],,,62.8,,231.58756,0.518595,35041.66656,percent of total billed charges,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,CIGNA [1000112],CIGNA [100011201],,,62.8,,832.18164,0.518595,35041.66656,percent of total billed charges,
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,CIGNA [1000112],CIGNA [100011201],,,62.8,,1431.35016,0.518595,35041.66656,percent of total billed charges,
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,CIGNA [1000112],CIGNA [100011201],,,62.8,,348.11924,0.518595,35041.66656,percent of total billed charges,
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,CIGNA [1000112],CIGNA [100011201],,,62.8,,1414.70188,0.518595,35041.66656,percent of total billed charges,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,CIGNA [1000112],CIGNA [100011201],,,62.8,,2798.4936,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,CIGNA [1000112],CIGNA [100011201],,,62.8,,2798.4936,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,CIGNA [1000112],CIGNA [100011201],,,62.8,,5307.9188,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,CIGNA [1000112],CIGNA [100011201],,,62.8,,2798.4936,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,CIGNA [1000112],CIGNA [100011201],,,62.8,,2798.4936,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,CIGNA [1000112],CIGNA [100011201],,,62.8,,2798.4936,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,CIGNA [1000112],CIGNA [100011201],,,62.8,,2798.4936,0.518595,35041.66656,percent of total billed charges,
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,CIGNA [1000112],CIGNA [100011201],,,62.8,,2798.4936,0.518595,35041.66656,percent of total billed charges,
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,CIGNA [1000112],CIGNA [100011201],,,62.8,,293.1504,0.518595,35041.66656,percent of total billed charges,
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,CIGNA [1000112],CIGNA [100011201],,,62.8,,6603.55816,0.518595,35041.66656,percent of total billed charges,
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,CIGNA [1000112],CIGNA [100011201],,,62.8,,6603.55816,0.518595,35041.66656,percent of total billed charges,
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,CIGNA [1000112],CIGNA [100011201],,,62.8,,6603.55816,0.518595,35041.66656,percent of total billed charges,
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,CIGNA [1000112],CIGNA [100011201],,,62.8,,6610.55408,0.518595,35041.66656,percent of total billed charges,
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,CIGNA [1000112],CIGNA [100011201],,,62.8,,9979.94992,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,CIGNA [1000112],CIGNA [100011201],,,62.8,,8912.00452,0.518595,35041.66656,percent of total billed charges,
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,CIGNA [1000112],CIGNA [100011201],,,62.8,,1214.97904,0.518595,35041.66656,percent of total billed charges,
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,CIGNA [1000112],CIGNA [100011201],,,62.8,,918.72632,0.518595,35041.66656,percent of total billed charges,
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,CIGNA [1000112],CIGNA [100011201],,,62.8,,238.18784,0.518595,35041.66656,percent of total billed charges,
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,CIGNA [1000112],CIGNA [100011201],,,62.8,,5379.76828,0.518595,35041.66656,percent of total billed charges,
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,CIGNA [1000112],CIGNA [100011201],,,62.8,,12008.5846,0.518595,35041.66656,percent of total billed charges,
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,CIGNA [1000112],CIGNA [100011201],,,62.8,,183.219,0.518595,35041.66656,percent of total billed charges,
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,CIGNA [1000112],CIGNA [100011201],,,62.8,,698.4616,0.518595,35041.66656,percent of total billed charges,
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,CIGNA [1000112],CIGNA [100011201],,,62.8,,1947.3652,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,CIGNA [1000112],CIGNA [100011201],,,62.8,,688.90344,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,CIGNA [1000112],CIGNA [100011201],,,62.8,,713.82248,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,CIGNA [1000112],CIGNA [100011201],,,62.8,,693.70136,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,CIGNA [1000112],CIGNA [100011201],,,62.8,,737.64252,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,CIGNA [1000112],CIGNA [100011201],,,62.8,,778.92096,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,CIGNA [1000112],CIGNA [100011201],,,62.8,,801.55408,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,CIGNA [1000112],CIGNA [100011201],,,62.8,,693.70136,0.518595,35041.66656,percent of total billed charges,
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,CIGNA [1000112],CIGNA [100011201],,,62.8,,737.64252,0.518595,35041.66656,percent of total billed charges,
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,CIGNA [1000112],CIGNA [100011201],,,62.8,,3446.14372,0.518595,35041.66656,percent of total billed charges,
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,CIGNA [1000112],CIGNA [100011201],,,62.8,,3192.94668,0.518595,35041.66656,percent of total billed charges,
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,CIGNA [1000112],CIGNA [100011201],,,62.8,,6531.85312,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,CIGNA [1000112],CIGNA [100011201],,,62.8,,494.69444,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,CIGNA [1000112],CIGNA [100011201],,,62.8,,494.69444,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,CIGNA [1000112],CIGNA [100011201],,,62.8,,6956.82072,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,CIGNA [1000112],CIGNA [100011201],,,62.8,,773.92836,0.518595,35041.66656,percent of total billed charges,
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,CIGNA [1000112],CIGNA [100011201],,,62.8,,858.80884,0.518595,35041.66656,percent of total billed charges,
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,CIGNA [1000112],CIGNA [100011201],,,62.8,,5453.06216,0.518595,35041.66656,percent of total billed charges,
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,CIGNA [1000112],CIGNA [100011201],,,62.8,,584.28492,0.518595,35041.66656,percent of total billed charges,
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,CIGNA [1000112],CIGNA [100011201],,,62.8,,64.47048,0.518595,35041.66656,percent of total billed charges,
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,CIGNA [1000112],CIGNA [100011201],,,62.8,,64.47048,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,CIGNA [1000112],CIGNA [100011201],,,62.8,,814.7358,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,CIGNA [1000112],CIGNA [100011201],,,62.8,,814.7358,0.518595,35041.66656,percent of total billed charges,
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,CIGNA [1000112],CIGNA [100011201],,,62.8,,814.7358,0.518595,35041.66656,percent of total billed charges,
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,CIGNA [1000112],CIGNA [100011201],,,62.8,,556.21332,0.518595,35041.66656,percent of total billed charges,
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,CIGNA [1000112],CIGNA [100011201],,,62.8,,729.21476,0.518595,35041.66656,percent of total billed charges,
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,CIGNA [1000112],CIGNA [100011201],,,62.8,,4725.45508,0.518595,35041.66656,percent of total billed charges,
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,CIGNA [1000112],CIGNA [100011201],,,62.8,,4592.19348,0.518595,35041.66656,percent of total billed charges,
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,CIGNA [1000112],CIGNA [100011201],,,62.8,,5210.52856,0.518595,35041.66656,percent of total billed charges,
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,CIGNA [1000112],CIGNA [100011201],,,62.8,,4592.19348,0.518595,35041.66656,percent of total billed charges,
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,CIGNA [1000112],CIGNA [100011201],,,62.8,,3550.09028,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,CIGNA [1000112],CIGNA [100011201],,,62.8,,822.19016,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,CIGNA [1000112],CIGNA [100011201],,,62.8,,720.33484,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,CIGNA [1000112],CIGNA [100011201],,,62.8,,822.19016,0.518595,35041.66656,percent of total billed charges,
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,CIGNA [1000112],CIGNA [100011201],,,62.8,,722.33188,0.518595,35041.66656,percent of total billed charges,
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,CIGNA [1000112],CIGNA [100011201],,,62.8,,7228.4684,0.518595,35041.66656,percent of total billed charges,
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,CIGNA [1000112],CIGNA [100011201],,,62.8,,7228.4684,0.518595,35041.66656,percent of total billed charges,
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,CIGNA [1000112],CIGNA [100011201],,,62.8,,659.5884,0.518595,35041.66656,percent of total billed charges,
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,CIGNA [1000112],CIGNA [100011201],,,62.8,,913.897,0.518595,35041.66656,percent of total billed charges,
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,CIGNA [1000112],CIGNA [100011201],,,62.8,,1163.7154,0.518595,35041.66656,percent of total billed charges,
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,CIGNA [1000112],CIGNA [100011201],,,62.8,,1551.5054,0.518595,35041.66656,percent of total billed charges,
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,CIGNA [1000112],CIGNA [100011201],,,62.8,,1551.5054,0.518595,35041.66656,percent of total billed charges,
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,CIGNA [1000112],CIGNA [100011201],,,62.8,,64.12508,0.518595,35041.66656,percent of total billed charges,
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,CIGNA [1000112],CIGNA [100011201],,,62.8,,2457.06884,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,CIGNA [1000112],CIGNA [100011201],,,62.8,,679.45832,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,CIGNA [1000112],CIGNA [100011201],,,62.8,,326.13296,0.518595,35041.66656,percent of total billed charges,
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,CIGNA [1000112],CIGNA [100011201],,,62.8,,5863.5104,0.518595,35041.66656,percent of total billed charges,
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,CIGNA [1000112],CIGNA [100011201],,,62.8,,5863.5104,0.518595,35041.66656,percent of total billed charges,
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,CIGNA [1000112],CIGNA [100011201],,,62.8,,549.657,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,CIGNA [1000112],CIGNA [100011201],,,62.8,,408.94732,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,CIGNA [1000112],CIGNA [100011201],,,62.8,,408.94732,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,CIGNA [1000112],CIGNA [100011201],,,62.8,,408.94732,0.518595,35041.66656,percent of total billed charges,
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,CIGNA [1000112],CIGNA [100011201],,,62.8,,366.438,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,CIGNA [1000112],CIGNA [100011201],,,62.8,,679.0564,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,CIGNA [1000112],CIGNA [100011201],,,62.8,,432.39684,0.518595,35041.66656,percent of total billed charges,
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,CIGNA [1000112],CIGNA [100011201],,,62.8,,432.39684,0.518595,35041.66656,percent of total billed charges,
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,CIGNA [1000112],CIGNA [100011201],,,62.8,,432.39684,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,CIGNA [1000112],CIGNA [100011201],,,62.8,,9781.75312,0.518595,35041.66656,percent of total billed charges,
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,CIGNA [1000112],CIGNA [100011201],,,62.8,,9781.75312,0.518595,35041.66656,percent of total billed charges,
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,CIGNA [1000112],CIGNA [100011201],,,62.8,,7345.0566,0.518595,35041.66656,percent of total billed charges,
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,CIGNA [1000112],CIGNA [100011201],,,62.8,,4545.55192,0.518595,35041.66656,percent of total billed charges,
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.00756,0.518595,35041.66656,percent of total billed charges,
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,CIGNA [1000112],CIGNA [100011201],,,62.8,,699.03308,0.518595,35041.66656,percent of total billed charges,
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,CIGNA [1000112],CIGNA [100011201],,,62.8,,1497.92444,0.518595,35041.66656,percent of total billed charges,
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,CIGNA [1000112],CIGNA [100011201],,,62.8,,1664.357,0.518595,35041.66656,percent of total billed charges,
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,CIGNA [1000112],CIGNA [100011201],,,62.8,,1664.357,0.518595,35041.66656,percent of total billed charges,
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,CIGNA [1000112],CIGNA [100011201],,,62.8,,696.2322,0.518595,35041.66656,percent of total billed charges,
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,CIGNA [1000112],CIGNA [100011201],,,62.8,,696.2322,0.518595,35041.66656,percent of total billed charges,
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,CIGNA [1000112],CIGNA [100011201],,,62.8,,2580.08148,0.518595,35041.66656,percent of total billed charges,
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,CIGNA [1000112],CIGNA [100011201],,,62.8,,2563.35156,0.518595,35041.66656,percent of total billed charges,
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,3331.54,0.518595,35041.66656,percent of total billed charges,
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,CIGNA [1000112],CIGNA [100011201],,,62.8,,1497.92444,0.518595,35041.66656,percent of total billed charges,
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,CIGNA [1000112],CIGNA [100011201],,,62.8,,2158.61184,0.518595,35041.66656,percent of total billed charges,
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,CIGNA [1000112],CIGNA [100011201],,,62.8,,2923.1202,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,CIGNA [1000112],CIGNA [100011201],,,62.8,,241.84908,0.518595,35041.66656,percent of total billed charges,
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,CIGNA [1000112],CIGNA [100011201],,,62.8,,725.54724,0.518595,35041.66656,percent of total billed charges,
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.71188,0.518595,35041.66656,percent of total billed charges,
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,CIGNA [1000112],CIGNA [100011201],,,62.8,,4189.74596,0.518595,35041.66656,percent of total billed charges,
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,CIGNA [1000112],CIGNA [100011201],,,62.8,,5037.28848,0.518595,35041.66656,percent of total billed charges,
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,CIGNA [1000112],CIGNA [100011201],,,62.8,,4125.77788,0.518595,35041.66656,percent of total billed charges,
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,CIGNA [1000112],CIGNA [100011201],,,62.8,,4125.77788,0.518595,35041.66656,percent of total billed charges,
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,CIGNA [1000112],CIGNA [100011201],,,62.8,,4285.6918,0.518595,35041.66656,percent of total billed charges,
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,CIGNA [1000112],CIGNA [100011201],,,62.8,,659.5884,0.518595,35041.66656,percent of total billed charges,
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,CIGNA [1000112],CIGNA [100011201],,,62.8,,2038.68896,0.518595,35041.66656,percent of total billed charges,
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,CIGNA [1000112],CIGNA [100011201],,,62.8,,915.12788,0.518595,35041.66656,percent of total billed charges,
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,CIGNA [1000112],CIGNA [100011201],,,62.8,,348.11924,0.518595,35041.66656,percent of total billed charges,
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,CIGNA [1000112],CIGNA [100011201],,,62.8,,348.11924,0.518595,35041.66656,percent of total billed charges,
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,CIGNA [1000112],CIGNA [100011201],,,62.8,,1165.05304,0.518595,35041.66656,percent of total billed charges,
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,CIGNA [1000112],CIGNA [100011201],,,62.8,,1648.9396,0.518595,35041.66656,percent of total billed charges,
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,CIGNA [1000112],CIGNA [100011201],,,62.8,,1648.9396,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,CIGNA [1000112],CIGNA [100011201],,,62.8,,1648.9396,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,CIGNA [1000112],CIGNA [100011201],,,62.8,,1648.9396,0.518595,35041.66656,percent of total billed charges,
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,CIGNA [1000112],CIGNA [100011201],,,62.8,,1648.9396,0.518595,35041.66656,percent of total billed charges,
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,CIGNA [1000112],CIGNA [100011201],,,62.8,,1648.9396,0.518595,35041.66656,percent of total billed charges,
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,CIGNA [1000112],CIGNA [100011201],,,62.8,,1648.9396,0.518595,35041.66656,percent of total billed charges,
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,CIGNA [1000112],CIGNA [100011201],,,62.8,,641.26964,0.518595,35041.66656,percent of total billed charges,
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,593.62956,0.518595,35041.66656,percent of total billed charges,
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,CIGNA [1000112],CIGNA [100011201],,,62.8,,3386.84168,0.518595,35041.66656,percent of total billed charges,
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,CIGNA [1000112],CIGNA [100011201],,,62.8,,9289.74652,0.518595,35041.66656,percent of total billed charges,
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,CIGNA [1000112],CIGNA [100011201],,,62.8,,9289.74652,0.518595,35041.66656,percent of total billed charges,
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,CIGNA [1000112],CIGNA [100011201],,,62.8,,348.11924,0.518595,35041.66656,percent of total billed charges,
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,CIGNA [1000112],CIGNA [100011201],,,62.8,,1664.357,0.518595,35041.66656,percent of total billed charges,
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,CIGNA [1000112],CIGNA [100011201],,,62.8,,832.18164,0.518595,35041.66656,percent of total billed charges,
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,CIGNA [1000112],CIGNA [100011201],,,62.8,,1414.70188,0.518595,35041.66656,percent of total billed charges,
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,CIGNA [1000112],CIGNA [100011201],,,62.8,,5443.4726,0.518595,35041.66656,percent of total billed charges,
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,CIGNA [1000112],CIGNA [100011201],,,62.8,,6689.8328,0.518595,35041.66656,percent of total billed charges,
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,19819.994,0.518595,35041.66656,percent of total billed charges,
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,19819.994,0.518595,35041.66656,percent of total billed charges,
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,19819.994,0.518595,35041.66656,percent of total billed charges,
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,19819.994,0.518595,35041.66656,percent of total billed charges,
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,CIGNA [1000112],CIGNA [100011201],,,62.8,,88.38472,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,CIGNA [1000112],CIGNA [100011201],,,62.8,,862.80292,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,CIGNA [1000112],CIGNA [100011201],,,62.8,,193.3298,0.518595,35041.66656,percent of total billed charges,
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,CIGNA [1000112],CIGNA [100011201],,,62.8,,9345.7076,0.518595,35041.66656,percent of total billed charges,
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,CIGNA [1000112],CIGNA [100011201],,,62.8,,10590.8746,0.518595,35041.66656,percent of total billed charges,
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,CIGNA [1000112],CIGNA [100011201],,,62.8,,10590.8746,0.518595,35041.66656,percent of total billed charges,
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,CIGNA [1000112],CIGNA [100011201],,,62.8,,197.87652,0.518595,35041.66656,percent of total billed charges,
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,CIGNA [1000112],CIGNA [100011201],,,62.8,,4562.87844,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,CIGNA [1000112],CIGNA [100011201],,,62.8,,1497.92444,0.518595,35041.66656,percent of total billed charges,
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,CIGNA [1000112],CIGNA [100011201],,,62.8,,366.438,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,CIGNA [1000112],CIGNA [100011201],,,62.8,,2204.36164,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,CIGNA [1000112],CIGNA [100011201],,,62.8,,2204.36164,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,CIGNA [1000112],CIGNA [100011201],,,62.8,,2204.36164,0.518595,35041.66656,percent of total billed charges,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,CIGNA [1000112],CIGNA [100011201],,,62.8,,2204.36164,0.518595,35041.66656,percent of total billed charges,
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,CIGNA [1000112],CIGNA [100011201],,,62.8,,490.51196,0.518595,35041.66656,percent of total billed charges,
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,CIGNA [1000112],CIGNA [100011201],,,62.8,,549.657,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,CIGNA [1000112],CIGNA [100011201],,,62.8,,1759.41736,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,CIGNA [1000112],CIGNA [100011201],,,62.8,,405.20444,0.518595,35041.66656,percent of total billed charges,
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,CIGNA [1000112],CIGNA [100011201],,,62.8,,337.52488,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,CIGNA [1000112],CIGNA [100011201],,,62.8,,1456.21268,0.518595,35041.66656,percent of total billed charges,
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,CIGNA [1000112],CIGNA [100011201],,,62.8,,832.18164,0.518595,35041.66656,percent of total billed charges,
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,CIGNA [1000112],CIGNA [100011201],,,62.8,,2931.7552,0.518595,35041.66656,percent of total billed charges,
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,CIGNA [1000112],CIGNA [100011201],,,62.8,,348.11924,0.518595,35041.66656,percent of total billed charges,
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,CIGNA [1000112],CIGNA [100011201],,,62.8,,1948.7468,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,CIGNA [1000112],CIGNA [100011201],,,62.8,,1948.7468,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,CIGNA [1000112],CIGNA [100011201],,,62.8,,1948.7468,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,CIGNA [1000112],CIGNA [100011201],,,62.8,,2248.554,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,CIGNA [1000112],CIGNA [100011201],,,62.8,,832.18164,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.40684,0.518595,35041.66656,percent of total billed charges,
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,CIGNA [1000112],CIGNA [100011201],,,62.8,,2089.65744,0.518595,35041.66656,percent of total billed charges,
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,CIGNA [1000112],CIGNA [100011201],,,62.8,,1281.55332,0.518595,35041.66656,percent of total billed charges,
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,CIGNA [1000112],CIGNA [100011201],,,62.8,,1470.12916,0.518595,35041.66656,percent of total billed charges,
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,2967.46956,0.518595,35041.66656,percent of total billed charges,
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,CIGNA [1000112],CIGNA [100011201],,,62.8,,4945.78888,0.518595,35041.66656,percent of total billed charges,
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,CIGNA [1000112],CIGNA [100011201],,,62.8,,2881.06304,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,CIGNA [1000112],CIGNA [100011201],,,62.8,,191.94192,0.518595,35041.66656,percent of total billed charges,
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,CIGNA [1000112],CIGNA [100011201],,,62.8,,1680.89852,0.518595,35041.66656,percent of total billed charges,
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,CIGNA [1000112],CIGNA [100011201],,,62.8,,1680.89852,0.518595,35041.66656,percent of total billed charges,
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,CIGNA [1000112],CIGNA [100011201],,,62.8,,728.00272,0.518595,35041.66656,percent of total billed charges,
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,CIGNA [1000112],CIGNA [100011201],,,62.8,,6062.5864,0.518595,35041.66656,percent of total billed charges,
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,CIGNA [1000112],CIGNA [100011201],,,62.8,,2989.07904,0.518595,35041.66656,percent of total billed charges,
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,CIGNA [1000112],CIGNA [100011201],,,62.8,,2989.07904,0.518595,35041.66656,percent of total billed charges,
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,CIGNA [1000112],CIGNA [100011201],,,62.8,,2143.62148,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,593.62956,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,593.62956,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,593.62956,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,593.62956,0.518595,35041.66656,percent of total billed charges,
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,CIGNA [1000112],CIGNA [100011201],,,62.8,,1591.97372,0.518595,35041.66656,percent of total billed charges,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,CIGNA [1000112],CIGNA [100011201],,,62.8,,1744.87916,0.518595,35041.66656,percent of total billed charges,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,CIGNA [1000112],CIGNA [100011201],,,62.8,,1744.87916,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,CIGNA [1000112],CIGNA [100011201],,,62.8,,2798.4936,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,CIGNA [1000112],CIGNA [100011201],,,62.8,,2284.53212,0.518595,35041.66656,percent of total billed charges,
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,CIGNA [1000112],CIGNA [100011201],,,62.8,,2527.37344,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,CIGNA [1000112],CIGNA [100011201],,,62.8,,2968.09128,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,CIGNA [1000112],CIGNA [100011201],,,62.8,,2814.48248,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,CIGNA [1000112],CIGNA [100011201],,,62.8,,153.90396,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,CIGNA [1000112],CIGNA [100011201],,,62.8,,1477.94776,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1318.172,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,CIGNA [1000112],CIGNA [100011201],,,62.8,,1537.86524,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,CIGNA [1000112],CIGNA [100011201],,,62.8,,1537.86524,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,CIGNA [1000112],CIGNA [100011201],,,62.8,,1537.86524,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,CIGNA [1000112],CIGNA [100011201],,,62.8,,329.7942,0.518595,35041.66656,percent of total billed charges,
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,CIGNA [1000112],CIGNA [100011201],,,62.8,,439.7256,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,CIGNA [1000112],CIGNA [100011201],,,62.8,,439.7256,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,CIGNA [1000112],CIGNA [100011201],,,62.8,,439.7256,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,CIGNA [1000112],CIGNA [100011201],,,62.8,,263.83536,0.518595,35041.66656,percent of total billed charges,
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,CIGNA [1000112],CIGNA [100011201],,,62.8,,2862.46168,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,CIGNA [1000112],CIGNA [100011201],,,62.8,,2722.24812,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,CIGNA [1000112],CIGNA [100011201],,,62.8,,1331.4856,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,CIGNA [1000112],CIGNA [100011201],,,62.8,,2722.24812,0.518595,35041.66656,percent of total billed charges,
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,CIGNA [1000112],CIGNA [100011201],,,62.8,,1331.4856,0.518595,35041.66656,percent of total billed charges,
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,CIGNA [1000112],CIGNA [100011201],,,62.8,,775.59256,0.518595,35041.66656,percent of total billed charges,
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,CIGNA [1000112],CIGNA [100011201],,,62.8,,3411.49696,0.518595,35041.66656,percent of total billed charges,
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,CIGNA [1000112],CIGNA [100011201],,,62.8,,3411.49696,0.518595,35041.66656,percent of total billed charges,
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,CIGNA [1000112],CIGNA [100011201],,,62.8,,3065.0168,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,2251.54956,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,2251.54956,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,2251.54956,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,2251.54956,0.518595,35041.66656,percent of total billed charges,
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,CIGNA [1000112],CIGNA [100011201],,,62.8,,2251.54956,0.518595,35041.66656,percent of total billed charges,
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,CIGNA [1000112],CIGNA [100011201],,,62.8,,1647.715,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,CIGNA [1000112],CIGNA [100011201],,,62.8,,133.93356,0.518595,35041.66656,percent of total billed charges,
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,CIGNA [1000112],CIGNA [100011201],,,62.8,,117.26016,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,CIGNA [1000112],CIGNA [100011201],,,62.8,,197.87652,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.58516,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,CIGNA [1000112],CIGNA [100011201],,,62.8,,780.54748,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,CIGNA [1000112],CIGNA [100011201],,,62.8,,109.9314,0.518595,35041.66656,percent of total billed charges,
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,CIGNA [1000112],CIGNA [100011201],,,62.8,,978.6438,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,CIGNA [1000112],CIGNA [100011201],,,62.8,,938.69672,0.518595,35041.66656,percent of total billed charges,
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,CIGNA [1000112],CIGNA [100011201],,,62.8,,1141.74796,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,CIGNA [1000112],CIGNA [100011201],,,62.8,,274.83164,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,CIGNA [1000112],CIGNA [100011201],,,62.8,,637.60212,0.518595,35041.66656,percent of total billed charges,
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,CIGNA [1000112],CIGNA [100011201],,,62.8,,316.93276,0.518595,35041.66656,percent of total billed charges,
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,CIGNA [1000112],CIGNA [100011201],,,62.8,,349.9844,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,CIGNA [1000112],CIGNA [100011201],,,62.8,,307.80792,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,CIGNA [1000112],CIGNA [100011201],,,62.8,,373.76676,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,CIGNA [1000112],CIGNA [100011201],,,62.8,,373.76676,0.518595,35041.66656,percent of total billed charges,
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,CIGNA [1000112],CIGNA [100011201],,,62.8,,373.76676,0.518595,35041.66656,percent of total billed charges,
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,CIGNA [1000112],CIGNA [100011201],,,62.8,,614.11492,0.518595,35041.66656,percent of total billed charges,
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,CIGNA [1000112],CIGNA [100011201],,,62.8,,681.57468,0.518595,35041.66656,percent of total billed charges,
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,CIGNA [1000112],CIGNA [100011201],,,62.8,,404.07404,0.518595,35041.66656,percent of total billed charges,
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,CIGNA [1000112],CIGNA [100011201],,,62.8,,404.07404,0.518595,35041.66656,percent of total billed charges,
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,CIGNA [1000112],CIGNA [100011201],,,62.8,,404.07404,0.518595,35041.66656,percent of total billed charges,
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,CIGNA [1000112],CIGNA [100011201],,,62.8,,7853.37864,0.518595,35041.66656,percent of total billed charges,
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,CIGNA [1000112],CIGNA [100011201],,,62.8,,7853.37864,0.518595,35041.66656,percent of total billed charges,
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,CIGNA [1000112],CIGNA [100011201],,,62.8,,7853.37864,0.518595,35041.66656,percent of total billed charges,
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,CIGNA [1000112],CIGNA [100011201],,,62.8,,8977.2914,0.518595,35041.66656,percent of total billed charges,
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,CIGNA [1000112],CIGNA [100011201],,,62.8,,8977.2914,0.518595,35041.66656,percent of total billed charges,
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,CIGNA [1000112],CIGNA [100011201],,,62.8,,1541.19364,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.6504,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.4576,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,CIGNA [1000112],CIGNA [100011201],,,62.8,,2698.2648,0.518595,35041.66656,percent of total billed charges,
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,CIGNA [1000112],CIGNA [100011201],,,62.8,,458.05064,0.518595,35041.66656,percent of total billed charges,
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,CIGNA [1000112],CIGNA [100011201],,,62.8,,1171.70984,0.518595,35041.66656,percent of total billed charges,
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,11658.82,0.518595,35041.66656,percent of total billed charges,
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,11658.82,0.518595,35041.66656,percent of total billed charges,
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,11658.82,0.518595,35041.66656,percent of total billed charges,
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,CIGNA [1000112],CIGNA [100011201],,,62.8,,1497.92444,0.518595,35041.66656,percent of total billed charges,
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,CIGNA [1000112],CIGNA [100011201],,,62.8,,1497.92444,0.518595,35041.66656,percent of total billed charges,
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,CIGNA [1000112],CIGNA [100011201],,,62.8,,2548.3612,0.518595,35041.66656,percent of total billed charges,
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,CIGNA [1000112],CIGNA [100011201],,,62.8,,2548.3612,0.518595,35041.66656,percent of 